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0818A
WORKERS'COMPENSATIONDECLARATION b�' CEA806G '°'81 APPLICATION FOR ELECTRICAL PERMIT �`��I hereby 5ffirm ihat I have a certificate of consent to self insure, � or a certit�cate of Nlorkers'Compensatron Insurance,o�a certified COUNTY OF LOS ANGELES BUILUING AND SAFETY • copy thereof(Sec.3800.Lab.C.) Po��Cy ND.- '�' �- Compafry � FOR APPLICANT TO FILL IN ODRESS.� . d. ��n.t ��� ❑ Certified copy is hcreby lurnished,. . . New Residential Bldgs.&Poois EACH NO. FEE � Certifietl copy is filed with [he�county buildirg inspection 1&2-Family,Sq.FL � = S LOCALITY �J��Nu� � . department. �� Multidamiiy Sq.Ft. - tiEartEsi � ���-��'�� ResldentialSwimmfngPools CRoSSSL ,�7 /�rui: OatO AppliGOnt OwNEH OR �J � � FIRIA NAME N(�� /+'" / - � .� CERTIFICATE OF EXEMPTION F WORKE � 2+ � � � qi� Ouilets:Rec Light—$w.— Z _ ��v�� � . COMPENSATION INS ANCE . :. ,. _.. . ADDRE55 (Thla aeetlon need not be completed if!he work Involved by the � Fist 20 . ., Total No. Additional GITY Tel.No. ,permit Is for one hondred dollars($100)or leas.) , .� �r �' . � I certify thzt in ih=performarxe of th=vrork lor which this permit � PUN CnECK is issued,I shall not employ any person in any manner 50 2S[o ' APP��CANT-� / / v/ � it 6ecome subject to the Workers'Compensation Laws. _ Lighting Fixtures First 20 ADDRESS ��7.. ,A� ��7 Y - Total No. � Additionat Date Appli�3n1 � CITY���� ��. 7e1.N�.:�_ � • NOT10E-TO�APPUCANT; It, after making this Certificate of Fized Appiiantes Not Over 1 HP � PERMIT � Exemption,you should become subjxi to the 6Yorkers'Compensation Range_Heater_ D.W. _ APPLICANi - / u/G �jlr provi=_ions cf the�eber Ced?,you must forthv.��th cemply rvith s:rh O��en_Dryer_ WA4_ � � ADDRESS �, �Cl, ���� ys�TJ' provisions oi this permit shall be deemed rewked. , Top —FAU_._�W.H._, LICENSED CONTRACTORS DECLARATION., Hood_Fan _ Other_ - � � � qTY- �, � �No. _�7j� .1 hereby�atfirm iha!I am licensetl untler provisions of Chapter 9 Disp.-—Poom Air Cond. _ uCeNSE On (commencing with Sec[ion 70001 of�ivision 3 of ihe Busine55 and REG.NUMBER // `y� Ciass. ��? Professions Code,and my license is In full force and etfeCt. � DiS?RiCT NO.. PROCESSE�BV � Povrer Appzratus&Large Appliances, �� � Size&Type HP,KW,KVA,or KVAR Lkense Num6er�����f Lic.Class� ..- .... -.... UP to 1 Incl.- . . .� FlNAL... . - . U Over 1 to 701nc1. DATE � Z���'7 yALIDATION � � contract ✓� 'toate '1"Z7-j7 over to ro so�nci. � - ` � ❑ 1 am axempt under SeC. Over 50 to 100 Inc. BY A� . .• W .. � Over 100 B&P.C.for thi5 rBaSOn L� N . Servi e�qs Swb�.M��n I Zrds'L . . . . h . . . Z. ....... . _ _.. . __ .. . Dzte: �U-200���p UrTd"er�6�V � � U � r. � Sgnaturo � 201-1000 Amp.llMer 600 V - - � .. 7 C,^.,�,.^..�, . ��❑ -- �- � Over 1000 Amp.or Over 600 V r �. .. Exemption for Reg.MainL Etect. � a •7 - � � � SINGLE FAMILY - -- --� - Temp.Power Pole&Appurtenances HOA!E OWNER-6UIL�ER OECLARATION - - --� - � -� �� ° °�a�7•z 5. I hereby aFfirm ihat I am ezempt irom tho Conhador's License Law Sign with One&anch Circuit� � � , ���1 7 r.,_ lor Ihe foliowin reason Secfion 70315,Business and Professions A'i'�'�'°^'-��y^B'=^=h Cir�i!s .,..-� - � 9 I Code): � G ;��C-I-�?�! -� ❑ �� V/✓ lyuav ._ ._ .. 1,as owner of the property,wilt do ihe work end the structure Misc.�G`onduits 8 Condu rs � In �r �3 is nol intended or offered for sale(Section 7044,Business Other(See Comp�te F e S�hedule)_ 5�� (/A�F�•+G IQ+G. antlProlessionsCoAe). IdJ� Z�_/`�U N� �w , �vrJ�"�v Pd�L '��v'/A � � CONSTRUCTION LENDING AGENCY ���'r u, ? � . . . . . . . I herehy atfirm that there is a construdion lerxfirg agency for the � � . per(ormance of the work for whith thie permit Is issued(Sec.3097,_. .pERMIT FEE--��"��6��� (Sub-7otal) ... . . - Civ.CJ. �. .PLAN CHECKING FEE _. . � Lender's Name � J� � PERMIT_ISSUING FEE . _ _ ,. . J�/ Lende�'s Address � � � � � I certify tha[I have read this appl'�cation and state that tha above_.._ TOTAL FEE - � � _ . . . . .... .. . . t . . .. . ., ._ . � Informatbn is correct.I agree fo comply with all County ordinances � and Stale laws regulatin� Elecirical wiring,2nd hereby authorize ' � representztives of this County to enter upon the above-mentioned���� - � � � � � ,� � ' � � � - � � ��� �- � � -�- - - propery or insp� rpo�s. � . SEE REVERSE FOR EXPLANATORY LANGUAGE . . . . . . . . ... . . .. ._. .. /'G 7� ignat o Permittee Date „ ; _ . . �4 :. . .' i__ ... . ..._. �r' ; - - ' `-- '-' �� �`1•. --';--'--i i—'— . _,_--� � ` 1�l ��`' � �” � � �' � I � � . . - ` � �' / � i: � , /' ; ' ! � � _ : ' �• r �; �: ' � i ' i ! t i.. � , ,~ �t , i � � � 11 J/ ,i. 'f�' I'.r' J � 1 i � i ; :. . .. �; _ �'` i � ' � _ i : i' �i. �i : .� � ��/;., ' j � � : . - ---- i .. .- ' .� , - I : � , 'r � _ � '-� ` � , � � � � '.�:! � •'� �� � . � ,. ; ! 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