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1805A
WORKERS'COMPENSAIION DECLARATION 76A663 t0/8� qppLICATl01� FOR ELECTRICAL PERMIT {� I hereby,aflirm tM1a[I have a cerfrfiwte of consent to self insure, CE-BOeG or a certif'�cate of Workers'Compensation Insurance,or a certified COUNTY OF LOS ANGELES BUILDING AN�SAFETY �� copy thereof(Sec.3800,Lab.C.) � ' ��Y N�ComParr/N��ST�-/f�'� FOq APPLICANT TO FIIL IN .. -..- :� JOB .. ... . . . Certified copy is Aereby furnished.. . , ,��'Q New Residenlial Bidgs.8 Poojs, EACH � NO. FEE- '���ESS �'- 1&2-Famil d� 5 — S LOCALIT'Y J/ _ � -� Ce tied copy is fited�with�he�canty�buildiig inspection Y,Sq.FL � y rtme�9� � . .. Multi-famity Sq.Ft. — CROSSSSL _ Q ,... . �i4/�i(/�� � . � �n,� .. __. .... _ .. . . .. _.�. _ ,Date(���=J.�.9�ADP��cant r✓e+-ac.�--� Residentiat Swimmirg Pools - ow�La o� �-.. ,. . - ' ' --' - .. . . FIRM NAME N E_-/� �� �� �'CEHiIFICA7E OF EXEMPTION FAOM VJORKERS' -'� p���s:Rec_Lighl_gw,_ MAi� ��� �' � � �-�� � � COMPENSRTION INSl1RANCE � � . -- � - -- �ADDFESS . . _�(Thls seetbn need rwt be compleled H the worK invdvetl by tAe First 20� permil Is for a�e hundred dollare(5100)or Iese.). . Total No. Additional qT /�CJ.���- �, Tel.Noy679 yr _ ��I certify thal�in the performance of the work(or which thie permit �. _-. ____....� ._... _.. . �NCHecK - � �ia issued,I shall not e I a ' . �pp��NT . . .-.._.. mpoy rry person in erry manner so as m . become wbjee[to the Workers'Compensation l.aws.�,..,, L'ghting Fixtures Frst 20�.- '- - ---�� - ���� -----�-� - -� AD�RESS- �-- -- -�� - ,..... . . ... � . . . .. .. Total No. Additional . ' . . . . . _ . . Date .,.�,. � Applicanb. .� . .....�� �...� CITY . Tel.No. Fiaetl Appiiances Not Over 1 NP TICE�..TO.APPLfCANi:-tl,;�after�making�tMs.Certificate of � �anvi ,�/j (�� ��, �emption,you shouid hecome subject to�he Workers'Compensation .. _-_Range.,___Heater_.D.W. _ APP�-�CANT �e� � •pivvisions of Ihe Labor Code,you must forthwith compty with such Oren_ Dryer_W M._ ADDRESS � (�, x ��f� �pmvisions or this Permit shall be.deemed revoked �,..� -. _ .__TOP �— FAU- _.W.H._._ . _ _ .. -_. . .. - . -� C�TY ���,/Q C��7��' Tel.No���y�� �� ��� � LICENSED CONTRACTORS DECLARATION-�,�� Hood_Fan _Other_ �I hereby at(irm that I em I�ensed�uMer.provisions of.Chapter g .. , ._. _ ____ . _ . uCENSEOR ' (comme�ing with Section 7000)ot Division,3 ot the Business and � Disp. _ Room Air Cond. _ " � nec.NunneER� -- " � � Cias�� - Professions Code,and my liceose is in full foree and efiect. . . ppWer Apparatus 8 Large Applia�ces�- -. . _. . oiSiAiCT NO. vROmCESSEo Bv } - �) /y Size 3 Type HP KW,KVA,or KVAq �� '1`�0.��� Q a License Number y "� � Lie.Class `~ - .-._ .� ...---UP to 1 Incl... -.. .. . .. ._.. �. . FlNAL - I . . .... . U . . _�=JE��t�_ " __�1� ove���o_io i��i. oare r� .11��i _ _ vnunnnoN.__ p �Contractor Date Over 10 to 50 Inct. ❑. ...... FINAL I am exempt under Sec. --���• �- ��� '�' � -. � Over.50 to 100 Inc..... __ �,_. �n ' U . .. . _ . .-`-- _.. ._- BSP.C.ior this reason Over 700 Y�` Q - Cn - . .._. __. ........... . . ..._. _. __....__.___ ._.. _ ___""_._._... Zr _ ...._. ___._. .__... . __ -'- Services.Swbd..MCC&Panelboards�� � -�--bafei"'�'�����--" 0_200 Amp.UMer 600 V Signature . ...207-�t000AmP-Under�600.V. .` .. . -. . .. . ._ .. .. _ � ..-.. ........ . --. . _ _--.. _. 18Q5A ❑ Exemptan tor Reg.Maint Elect. �r 1000 Amp.or Over 600 V .._.. _' __ . ._. . _ , , _ _ i, ._ __2- ' SINGIE FAMILY .. _.Temp.Power Pole g Appvrtenances. . r • o 0 . .._.. ... .. ........_._ ..i..., ..._. \ HOME OWNER•BUILDER OECLARATION Sign with One Brench Circuit � °� �1 a,V �5erahy affirm ihat I am exempt from the ContratAx'S Llcense Law � -'ior the foliowirg 2ason(Section 7031.5,Business and Professbns -" �Additional Sgn Branch Circuits-�� ��-� -��- . ... . __ ....._ _ . �., �,,.,_,.,z . CodeR e-c i�� J.,_ �U - Miso.Conduits&Condoctors.._--..--.._ .._.._ _. .�. _._ . . _.. . . ._...... _. _ ._ . ... . �9,L 2-�'�'7 � ❑ I,as owne�of the properry,will do the work antl the s!rudure p�her(See Complete Fee Schedule)_ is rmt intended or offered for sale(Section 7044,Business ... _ . _ . _. _ . ,_ , and Protessions Codel. . .. _. . . .. . -. ._._-.... CONSTRUCTIONLENDINGAGENCY � - �-�-�-- �- - -- � . .---..._.____-._. 1 hereby alf,rm that the2 is a eonstruction Icnding agency for the performance of the work tor which this permit is issued(Sec.3097, �� PERMR FEE ���-� --����"�- �� ���---�-��-(Sub-Totat)� -' - � ._ . . __.•. _.. ._ . .. .. _ ___.._._ _ Civ.Q�. a � _ . ..PLAN CHECKING FEE.-..___ ... -.-.__. ... --_. _. .. ... .. ._.. ._.._ ._..... Lender's Name - ��� � ��- -PERMR ISSUWG FEE_ _... . . _- -- � -� -- - ._�O . .". . . _ . .. . --�.-._.. .. lender's Address � � � - I tertify that I have read this applicalion and state that Ihe above -- TOiAL FEE . _. ._. . ._.__...._.. .. � . . .___ . _ .._ _ _ .. . ._. _ .. ._.._. ._ ... inFormation is correct.I agree to compy�wilh ali Counry ortfinances � ana State lavrs regulatirg Electrical winng,and hereby authorire .. .� � _ . . . . .. .. .__ .__.. . ... __ _. � �___ ._.. . _ . representatives ot this County to enter upon the abo mentioned �-- � -� � � ��' -� - - - ro fa inspection porposea --SEE REVERSE FOR EXPLANATORV LANGUAGE--�-- - . . _. � _._ . .. /�'�C��e_ Q/.�� _ __ . .. SignaNre of Perminee � Date � � C-7 . - !.,.�'_ :C_:,�_ Cv�:.r. . �, ''�� �:,� ', ' �� ; '%' � i � �' f .. . � . -, � �C' ` ! If � I � ����= !, i, � /: I k � :i . %i � � ; / ( ; � I + �. f- �; -:� �� �j � � i i.,,F'.'� i ,� � '+ '� i � E i •' � - i ��`'i:�� ,f�� i,. 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