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, WORKERS'COMPENSATIOfJUECLRkATION T6A663 10/87 . �PPLICATION �OR� �L�CT�ICAL PERNIIT - � �
� 1 bere6y affirm-that t�have a cerYrficate of�co�senr fo self �'�G . �
insure,or a certificare of Workers'Campensa�ion Insorance, COUNTY OP LOS ANGELES BUIIQING AND SAFETY
� or c certified ropy ihereof(Sec.3800,tab.C.) �
vo��cy No.�22�4A�a��mr��r _ �i(1� Foa�reuu,Hs ro r�u x� AD�R��j ' '
_ � � Gertified copy is hereby furnished. - New Residentiol 84dgs. Is . E°'�t� NO. FEE .
�. 'Certifiad capy is fitad with the munty building inspec- �g�-Fa�^��Y�59� E� — S �OCAII
�tion deportment . � Mof�i-famiiy Sq.Ft � — 'NERRE5T �
- �� �� Residential5wimmingPools ��� .
Da1e�—�2—AS_ Rpplicanc `i' �F'f_-T�Yrf*[?T(� OWNER OR
- . . FlRM NAME
�� CERTIFICATE OP EXEMRTIpN FROAk WORKERS`��� OuNefs:Rec�ight_Sw._ -�'« -
- � - COMPENSATfQN INSURANCE . - n6DRESS
- (This s4tTba a�ed not bo-cem�aled U Nw arork i�trolrad by First 2t3 . . CITY �T
� the parmit fa for ons hundrod dollon(5100)w less.} Totot No.� Additional � -
I certify ihat in the performartce�of ihe wwk for which this • . - . ��� . �
-permit is ig5ued,I 5}wI}n01 employ ony person in cny mantter - �
. w as to 6ecome subject to the Workers"Compensation Lows. lighting Fiztures First 2Q � ADDR€$S �
- � - Totol No. AddPtionai .. . . �
CI'fY Te4:No. .
- Date applimnt � Pized Appliances Not Over t-HP pE�}T
� ' N�TICE TO APPLICANT: If, after making�his Certcficate of qppLG�ANT �� n
' Ecemption, yo��should.becnme subject to The Workers' Range_Heater_Q.W. _. �r'F:r. F.fF1 �
Compensation provisions of Yhe fabor Code,yov�must forth- -� Oven _pryer _W.M.— . ADDRE . - �
'. with comvpky with w€h.provisions or ihis permii shaf! be Top _FAU —W.H.— �
. deemedrnvuked. � � � � - GTY • � Te4.No:
-. LICENSED CONTRACTORS DECLARATION H� —Fan �Other_ -
- t krereby offkm thot k om licensed under.p�ovisions of Chopter 9 � ��s � _..Room Air Ccxid. — ����
P' REG.NUM&ER 4�Q�I4S CMss(�"`-10 - �
-(commer�cing wi�M Secti�J41Q4j_sf.QirisiQn$�€iF��@u�i�ss�� pau,er Apparatus&Large Appliances - � DISiRICT N6. �¢ PROCf55ED BY -
. �nd Prafesswns fade,o�d my license is in full force and effect. . .. }
Size&Type HP,KW,KVA,or KVAR �"
ticense Numb��.74R I�t.Ctass�-�n - Up to t IncL - FINAL - � -- � �3
� Over 7 to 10 i�ct. QAFE t �
� ConrractorF'lc+r�i-rir�al �ofe 7-22-A5� .. � . - � '� 1�, � YALtDAT1011 . . O
� ❑ . . Over}0 to 50 IncL FfNAf � -
1 um exempt under Sec Over 50 to 100!nc BY w
B.&P.C.for this reawn �e`�� � a
N
- .. - Services,Swbd.,MCC&Paneiboards ��� Z
Dafe: - -6-200 Amp.Urtder Kq V �
�� Signoture 2(li-tOQ6 Amp.Unde�6W V --- - =1��,�1 A
- ❑ . -Over 1 WO Amp..or Over 60D Y �
Exemplion for Reg.Mainf.Eletf. kr-'��� °�.2
SINGLE FAMILY . Temp.Power Pole 8 Appurtenances -� • ����(�
. HOME.0INNER-BUILDER�ECtARATiON Sign with One Branch Circuit - '
1 here6y aHirm that i am exempt from the Coniractor's License •e � (j�,��k.
� Law�for the�foilowing reosoo($etfion 7031.5, Business and Add'fiorwa$ign-$raochCircuits � _ _ !
Prafessiarss Code): - - _ - �'],�S..�� �
.❑. I,as owner of ihe p�operty,will do the work and the Misc Coaduits&Conductors - . - ;
structore is not intended or.offered for saie (Section Other j5ee Compfate Fee$chedule}_ � ► - � . .
7044,Businesz ond Professions Code). ;
� CONSTRUCTIQN LENDfNG AGENCY , - - - � ,
I Rereby affirm thaf ihere ie a construction lending agency for � �..
ihe performance of ihe work for which this permit is issued PERMIT FEE � . (Sub-To�al) . - - . _. ��I
� (Sec.3Q47,-Civ.�C.). � . . - . . '.
PLAN C#iECK4FVG FEE � � . .
Lender's Name � ��
- . � PERAAlT ISSUING FEE., � - .. -- ;
lende�'s Address � � . � � " � . �.
- 1 certify that I have read this application nnd state that the TOTAL FEE. � - � ��
abore inforrrwtion is correct.I.a9ree ro comply with all Counry . . � � �.
�ordinances and Siate laws regulating Eledricol wiring,and � - . '�.
hereby authorize representatives of this County to enter upon � � � . !
the bove-meniioned property for inspec3ion purposes: - � �
SEE REVERSE FQR EXPIANATORY�ANGUAGE
��t-�711�_ �-�.5-`
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