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1816A
WORKERS'COMPENSATION DECLARATION �6A� ,o�e, qpp�ICATI�N FOR ELECTRICAL PERMIT � I hereby affirm Ihat I have a certificate of cansent fo self CE-806G insure,or.o ceriificate of Workers'Compensation Insuronte, COUNTY OF LOS ANGELES BUILDING AND SAFETY or a certified:co�py.��hereof(Sec.3800,Lob.C.) F❑ol�icy No.�y�7v/�3�mpony�N�//S��jL� FOR A�PUCANT 70 HlL IN pDDRESS p{ D��� Cer�iiied copy is hereby furnished. .�/�� New Residen�iol Bld9s.8 Pyols Ee.CH NO. FEf 1 8 2Fomil 5 FI. b� E — 3 IOCALIT �-/ � Certiiied copy is filed with the covnty building inspec- Y' q' _ NEARESi . . � epar� ent � Multi�family Sq.Ft. �ROSSST. �/1 Residenlial Swimming Pools ONINER OR Oate —^' ApplitoN � FIRM NAME � � CERTIFICATE OF EXEMPTION FROM WORKERS' _ Outlets:Rec—light_Sw._ � ��� ��- COMPENSATION INSURANCE ADDRESS Fi�st 20 C (Thi�t�etten na�d nof M compl�fed iF Ih�wo'k(nvolv�d by Total No. Addi�ional ��ri ��Tel.No. 7 y Ihe p�rmit I�for on�hundr�d dollorc[5100)or los�,) . ttAN CHeCK �I certify ihat in Ihe performonce of�he work far whith this A7PLICANT _ permi��s iswed,1 shall not emptoy ony person in any monner - — so as ro become subject to the Workers'Compensation laws. lighting Fiztures First 20 ADDRESS � Toral No. AdditSonol CITY Tal.No. . Do+e Applitant Fixed Applionces Nat Over 1 HP PERMii ? � f YE 10 APPLICANT: I(, ofter moking�6is Certifimre of APPIIUNT��/ n � E...,{ptlon, you should 6ecome subjecl fo the Workers' .Ronge_Heater_D.W._ . Compensotion provis�ons of ifie Lobor Cvde,yov must forih. Oven _Dryer �W.M.— ADDRESS X /� with comply with suth provisions or this permit shall be Top _FAU —W.H:— G deemed revoked. CITY � ' ���Tel.No.�'r y . Hood _Fan _Other_ ii�Nse OR LICENSED CONTRACTORS DEQARATION� � Dis _Room Air Cond. — �`(�3 Closs�/� . �I hara6y affirm rhot I om Gcensed under provisiona o(Chapter 9 p' aEG.NUMBER (commencing wirh Section 7000)of�ivision 3 ot�he Business power Apparaius 8 lorge Appliantes DISTRICT NO. � ` PR�D BY O}.' ond Mofessions Code,and my license iz in full force and eHec1. a 0.`a �.� V ,y�'�2 C,� Size 8 Type NP,KW,KVA,or KVAR licensa Nomber �v V�" lit.Class � Up to 1 IncL FINAL � DATE �I .��t� VALIDATION � I�—' �f � (�� Over 1 to 101nc1. - U Contrado�`--���',� Oote s� Over lO fo 50 Ind. ❑ FINAL � W I am exempt under Sec. Over 50�0 700 Ina BY � 8.8P.C.for this recson �ve��� �' '�`1 8 1.b A z _ De e. Services,Sw6d.,MCC 8 Panelboards � #• o o a .2 0-200 Amp.Under 60p V . . - SignpWre 201-1000 Amp.Under 6W V� I � 1 2 1.4 6 � Over 1000 Amp.or Over 600 V � Exemption(or Reg.Maint.EIecL � • ° � ��.�l�J= SINGLE FAMILY Temp.Power Pole 8 Appurtenances � \ HOME OWNER-BWLDER DECLARATION 5�9�,,vlth One 9ranch Cirwi� O 9�P G—c�,O ,kby offirm�hat I am exempt from rhe Conrraclor's Llcense qdditional Sign Branch Circuits ldw for Ihe following�eoson(Section 7031.5, Busingss a�d , Profession:Code}: . - � ❑ 1,os owner of the properly,w��l do ihe work ond the Misc Conduirs&Conduc�ors - ztrucfu�a is not iniended or oifered for sale(Settion Other(See Complefe Fee Schedule)_ ► 7044,Businets ond Professions Code). CONSTRUCTION LEN�ING AGENCY I hereby affirm that there is a con:truction lending ogency for � � . . � ihe performance of the work for which this permit is issued PERMIT FEE - � (Sub-Total) �(� (Sec.3097.Civ.C.). . . . � PLAN CHECKING FEE ' � . lender i Name � PERMIT ISSUING FEE � - Lender's AddresS /'7/ /l � I cerfiiy that I have read thiz applitotion ond s�ate�hat the TOTAL FEE d •y - obove informolion is correct.I ogrea fo tomply wi�h all County ordinante5 ond 51aie laws regulofing Eledrltoi wiring,and . . � , hereby outhorize representatives of this County to enicr�pon rh ve-menuoned p�operry for tnspeUioyr},pv�s� SEE REVERSE FOR E7(PLANATORY LANGUACE /���`�tSGCX ` / S�gnaWre ct Permittee Dote ., '�� �� t, , . � , . � �' � '�.;'� ��� '� �� �_�� ���•° /� �ty' '` � �.'�, � ,r i �,f; �`� �,�/ ' , ` ' . , . - .` � i � ��•1 v1� ,�� ,, ' . , y�.` `rf '�� \� �` � .,�`. .i ., �'�'!'. ',._ , (.� � � �i�' �v. 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