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WORKERS'COMPENSATION OECtARAT10N ��`� �Q�81 .ppp�1eqTlON EOR �ELECTRICAL PEftMIT � ��
I here6y:affirm that I hove a certifimte af wnsent to self CFBO6G
in;ure,or o cenpfkate of Wwkers'Compensatian inwra�ee, COUNTY OF LOS ANGELES BUIlDING AND SAFETY
or'a certified copy thereof(Sea 3800,Ln6.Cj . � . i
. P�ol�icy No. n?�A���mpanY .$,� . . FOR AP/IIUNi TO FLLL IN- �E� _ � .
. �Gerti£ied copy is hereby furnished. New Residentiaf Bidgs. � �`� NO. - FEE
Certified copy isf"rled with the Cou�ry bui4d'rng inspet- 1 8 2-Family,Sq.F�� b — S LOCAUT
tion department..- . - . � � . . . Multi-family Sq.Ft. — tJEARESi - -
x n Residential5wimmingPoofs ��RQp � i
.� Date 7..7?-R4 APPiicant.-.'�,' j'�'�-F�`j'j?.j(,' FfRM NnME
� - -CERTEFlUTE OF EXEMPTION FROM WQRKERS � Outlets:Rec_..,._Lighi_Sw._ � � qpDRE � 1Q']4 Pc�]t �T j} _ I
- COMPENSATION fNSURANCE � . -
(This soefion aoad aor bo ooenple�.d ii the weA�h�rol.vd 6y First 2(T ClTY . T
� tha pQ�wtt is for wro-6undcod do4lars(ZIOOJ w Ins:}- . Toral No.� ,qdditionat- Q - i
� ttAN CIiELX
I certify.that ia the-performante of Fhe work��fo�`whitb lhis APPLICAM - �
. - .permit is iuuad,1 shok not emplay any persa7 in any mnnner � � -
sn as to-becomesu6ject to the iNorkers`�Gompenwtian Laws. Lighting Fixfures Frsi 2Q ADDRESS � -� i
� � - � - . Total No. A¢ditional CITY Tel.Na �
Dafe � Appl'rcant - - fixed Appliances Not pver!HP PERMR - � �
-NOi10E T6 APPL(CAAfC: If, aher moking ih'rs Certificate of - _ p���M. �e a � j
- Exemption, you shoold become sob[ect to the Workars" Range_Neeter_D.W._ . �
- Compensotion provision�of the labor Eode;�yau must forth- �Oven !Dryer —W.M._ � ADDRE55 j
� wiPh camply with such provisions Qr this permit shall 6e Top _PAU —W.H.— -� - - �
� .deemed revoked. - - CiTY Fel.No. j
- Nood _Pan _Other._ � - y
� - . L4CENSED CQNTRAETORS DECLARATION LfCENSE .
... -t heceby aHirvn ihW f ans licensed-��ader prouisions-o€Fkwpfer 4 - �Disp. _Room Air Cond. — RE�.NUMBER .Ctass. �
� {commencing wi�h Sectwn 7pf1U)ef Divisian 3 of the Business DlSTRlCT NQ. PROCESSEp BY
- .a�d Professions Code,-and my Ircense�s�irs#�Itforee and effect. Power Apparotus&Large Appfiances �� }�
. � -� � �� Size 8 Type HP,KW,KVA,or KVAR � Q
License N�mber 42�748 !ic CEass L'-�� � � FINAL V
Up to i I�cl.
E?ver7 to 101ncl. QATE �2 � \. u Tbb �
� � Controclor��EC1'�"i[`al� Qate� ���2-grJ-.--. -_.__- ---- __ _. �
❑ Over IQ to 50 Incl. FINAL � . �
I am exempt under Sec Over 50 to 100 Inc. HY �
. $.&P.C.fw fhis reasan 4ver 100 , , �
�. - . . . Da�. Services,Swbd.,MCC&Panelboards - � � -
� � � .. � 0-2W Amp.Under 606 V _-
� Signature 20T-16W Amp.Under 6W V � �
. � Over 7000 Amp,or Over 600 V _ ��6 4^J�A
Exemption ior Reg.MainL E(ect.
SINGIE FAMIIY � . . Temp.�Power Po�e&Appurtenances . #��� � �2
. HOME OWNER-BUIL6ER DECLARATION $ign with One B�anch Circuir ..I •�Q rj,5 0
� - F fiereby aHirm�hot 1 am exempt from the Controdor's License Additional Sign 8ronch Circuits � -
Law far ihe follawing reason(Section 7031.5, Business ond � - - ��• 1 q 5.5 C c=.�
Professions Codej: . - � . - .
❑. 1,as owner of the properfy,wil4 do the work and the� M;sc Conduits&Conducrors - O Z.Z S'-$�J
� strudure is not intended or offered for sale (Senion Other(See Complete Fee Schedute)_ �
- � 7044,Bosineu and Professions Code). � .
� CONSTRUCFION LENDING AGENCY .
' 1 bereby afEirm that�here�is a ronsiruction lending agency for . -
' ihe per€ormonce of the work for which this permit is issued PERMIT FEE - (Sub-Tobl) . . -. ..
' (Set.3097,Civ.C.). � - - � . �
i
� - - FLAN CHECKING fEE . _ �
.- . Lender`s Name - /Q - .
� - � - PERMfTiSSUING FEE ! - '�
� Lende�'s Address �i
� I certify thot 1 have reod this applimtion and stote�hat the FOTAL FEE _ ��
- a6ove infwrtwtion is correct.I agree to comply with all County � �I
- . ordinaaces and Sto�e�qws reguloting Eleciriml wiring,and � �
. hereby authorize represeNatives of this County�o enter upon � - - � � - � _
� she9�°ove-mentioned praperty for inspection purposea �
. I�-���`y�!���^-�J _^ _-_— SEE REVERSE FOR EXPIANATORY tANGUAGE
��
Sigaature of Vermittee- �Date `
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