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1716A
WORKERS'COMPENSATION DECLARATION 76A883 �a�e� APPLICATfON FOR ELECTRICAL PERMIT � I hereby alfirm that I have a certificate oF consent to sell insure, CE•Bo6G or a certificate oF Workers'Compensatbn Insurance,or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY copy thers c.J3800,Lab.C.) / L�y� �/ Po��I77'�y N0.�� �/ (',pmpafly/ND�JAL/!7 f+/7 FOR APPLICANT TO FlLL IN ' JOB � '. S LL�'V �/ /'�� � �Certified copy is hereby furnished.,._ . �N/�. New Residenlial Bldgs.8 Poo �EACH N0. � �FEE� aoDRE53 /�K. Certified'copy Is�filed with the f�jbunty buildirg inspection 1&2-Famiy,Sp.Ft.� S — `� LOCAIJTY ��. f1�en ' "'�"' <-%' V/'/ �� Mulli•family SG.Ft. — NEAREST.. - .� CROSS ST.. Date Flpplican{ Rp.Sidential SWimming Po01S owNER OR , . . . . . - . -. .' FlRM NAM CEHTIFICATE OF EXEMPTION FROM WORKERS' � �� ' MAi� � /i �. � �� - -COMPENSATION INSURANCE�� •� - Outiels:Rec—Li9ht_Sw.— , qooRE55 -(This eedhn need not 6e completed if the wbrk Involved by the First 20 . qTY (� Tel.No. permR Is for one hurMred dollare(5100)or Isae.)� - Total No. Additional � P / � I certify that in the pe�formance of the vrork for which this�permit '� - qp�puCnNT K is issue4 I shall not employ�ary person in airy manner so as to � - — 6ecome subjett[o ihe Workers'Compensation Laws.... Lightirg Fixtures First 20 --�� �- � -- � - 'ADDRESS �- ' � .. , ... . � . � ' . ' _. Total No. Additional CRY -.. . . .� Tcl.No. NaOIICE TO,".APPLICANT: IF,�s' .. .. . . . Fxed Appliances Not Over 1 HP rEqMiT �� y fter making �this Certificate of � i�� Exemption,you shovM become subject to the Wakers'Compensation Range_Heatcr D W. _,, APPl1CA1J� � provisivns of the La6or Code,you must fathwith comply.with such Ovzn_Dryer_ W.M._ ADDRESS •v, ���� provisions or this permit shall be deemed revoketl. �� .. � Top _FAU-_W.H._ - � � CITY ��� ���� Tel.No����f�p/ LICENSED COMRACTORS�ECLARATION � Hood_Fan _Other_ I hereby atfirm�that I�am licensetl mMer provisions of Chapler g � Disp. _Room Air GOM.-- � � - �- - .�... uceNse oH ._ � -7 �- - CtassC/� (commencing with Section 7000)of Oivision 3 01 the Business and REG.NUM6ER � � ROfessions Code,eM my IiCenSe is in(ull 1orCe and eflect. . . -p�yer Appara'us 8 Large Applianees� -��- - - - . _ . DIS7p�C7 NO. R7oCESSED BV . . .. . .._ .. .... � � � ' [yp „�� �_/O Size 8 Type HP.KW,KVA,or KVAR 1 � �0�1 On p O 7d�U _. .. .. . . . . . . . . . Lkense Number Z Lic.Clas� Up to 1 IncL FlNAL ��^� r/'i• - V ��� �L�Yi � Date Over i to 10 Incl. DATE `7 dd .ypLIDATION ._ � ��Contraetor • Over 10 to 50 Incl. � � � FINAL ..❑. I am exemPt under Sec. ... ,.. ' . ...- Over 50 to 700 Inc... .. ... gY...- . . �. . . . ..... .. .. W B.&P.C.for this rcason OvPr 100 � N __.. . �_.._ _ ._ _ �Services,Swbd.,MCC&Panelboards -� � � �.--- � � - � �-� � - - Z _ ..._._.. _ . . . Datei-- 0-200 Amp.Untler 600 V Signature _...-201-1000 AmP.Under 600 V.. -. . ..- . . ..... . ... .. . .... .. . -. �.� 7�.6 A . � - - . .. ___ . . . . ❑ Over 1000 Amp.or Over 600 V #• • e a •7 Exemption ior Feg.Maint.E�ect. � � - � - '�'� � � - �-- - -��� - ...' . ..-_. . ..SINGLE FAA!!LY... . ..... ... .: . .TemP.Povrer Pole&APWrlenances � ( � •�/2.9�i. . HOME OYVNER-Bl11LDER DECLP,RATION Sign with One Branch Circuit o � e C I hereby affirm that I am exempt from the Contractor's Lkense Law� 2����%� 1or the following reasnn(S?ct�on 7031.5,9usi.^?°s eM Profes_ior,s � Adddional Sgn Branch Ciraiiis- - -� - �- - � - � ��- codel: ��.2�-88 ❑ I,as owner of the p/operry,will do the vrork aM the structure Mfsc.Conduits d Conductors � ��� �� � � � �-� ���' � � � � - �� �"" ���- � �" Is rrot inteMed or offe2d for sale�Section 7044,Dusiness . Olher(See Complete Fee Schedute)_ � . . . .. .. .. . .. ..... _' and Professions Code). CONSTRUCTION LENDING AGENCY - "- - - ' "� " �" -��-� I here6y aflirm that there is a eonstruction lendinq a9ency for the performance o1 the xrork for which this permit is issued(Sec.3097,--- pERh1R FEE ��� - � �� �-(Sub-Total)�� �� � - - - - �---� -� - Giv.C.J. ' �.. PLAN CHECKING FEE. . . - . .- . . - -- ._ _._.. .. .. . . . _ .. . Lender's Name �- PERMIT ISSUING FEE � -- � �- � -- --- - /(� � - �� -� ��� � �� - -.-� � - .. Lender's Address /� � I certity that I have read this application and slate that the e6ove -- TOTALFEE . . _ . . . . .. . . %a�� . __ . _. . . . ._ __. information is correct.I agree to comply with all County ordinances . and S�ate Iaws regulating Elecirical wiring,and hereby authorize . _.__ . .... . .. . . .. . _ . . . ..... . . . . . ... .. . _ .. . . .. .. . _.... . representalives ot ihis County to enter upon the above- entioned � prop r inspection purposes. /I�/���-���:(' ...... . ._ _-SEE REVERSE FOR E%PLANATORY LANGUAGE . . . �j� - ....... . _ .. . .... . . Signature of Permittee Date . ��� - . . , � C" ..'. �-- . •.�J.�.\.�. :/�: .. _! j,� I �� �/ � I I I I. -�� � I ! � - _ ! � ' , , � �: ;,�: � I�• r�. 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