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1793A
WORKERS'COMPENSAT�ON DECLARATION � 96nfiea taei I I hereby affirm tM1at I have a certifcata of con5ent to selF insure, CE-806G APPLICATION FOR ELECTRICAL PERMIT � . or a cer�i<�ste ot Workers'Compensation Insurance,or a certitied COUNTY OF LOS ANGELES , BUILDING AND SAFETY ' � copy thereof Sea 3800.Lab.CJ / � .Po❑Ilcy No��.Compar7y'NQY.��/� FOR APPLICANT TO FILI IN . . . 'pB. . . � N �/C.l7 .�--�`. ,Certified.copy is hereby fumished. . , _/I��- New ResMential Bidgs.S Pools � EACH. N0. _ .FEE aooaess � � 1 8 2-Famil _ — LOCALITY� . �'i .�� . � Certitied co�py i9 filed with�the'"counry buildirg inspectlon y,Sq.FL �� S — g � y Sq.FL NEAREST Q C� . .dQp men . Ppi �.�.,/� �. ' `���/� Multi-lamil ..._ .. ._' __.. . CROSSST. - ., �:�. ' �� .O � Residential Swimming Pools _,O �� J Date � � A licanl��i�+/ OWNER OR . .. . . . ..,��. - �, . ... . _�_ ( �_ FlRMNAME � G_�� g , �+ � � .� CEF7fIFICATE-OF EXEMPnON FROM WORKERS' �. �p�tiets:Rec—Light_Sw— :'. � � •'. f, \, � ODRESS . . ,./�JC �3�/ ��• COMPENSATION INSURANCE� - � � �(Thls settbn need not 6e compieted ff the work i�volved 6y the First 20 permit ia for one hundred doilars(5100)w Iess.J Total No. Addilional�-� - CIT � (��� �" Oa Tel.N. 7�G I certity that in the performance of the.work tor which this permit . . . . , rvN cHecK- - - � .is.issued,.l shall not empioy arry person in atry manner so as to � APPiJCAM� � �_ �become subject to the Workers'Compensation Laws. Lighting Fixtures First 20�-��� ADDRESS -� � - --- � - �. . ,.. �� PP Additional ._. . . . . . . . � NOTICE�TO APPLiCANT•ppF,e aRer,ma Fixed A Iiances Not Over 1 H CITY �- - -- ��---�� Tel.Na . � ' Total No. king.this�Cert'rfiCate of P � PERMIT / /� ��emption,you should become sub�ect to the Ylorkers Compensation . Range_Heater_DW. _ A���'�T ������ , ovisions of the-Labor Code,you must forthwith comply with such Oven— Dryer_W.M._ AODRESS .�,--�� �V �f� � � � -prQvisions or this permi(shall be deemed revoked. ., � _ . Top.,_.FAU__W.H.____. _,_ _ __ __ /,/ . ,LICENSED�CONTRACTOR$DECIARATION� , Hood_Fan _Other_ CITY ��J � ���7et.-N. I/ly 6� :. ,; .. : ,., I.hereby affirm that I,am�licensed under.provisions ol Chapler 9 _., .___pi5p.-_ RODmAIrOpnd.__ LICENSEOR p�q�p� � /v�p (commencing wilh Secfion 7000)of Division 3 of the Business and ---��� aEG.Nunnaea 7V cid�3 - ��-� - ��-r Professions Code,and my license is in NII force and elfect.`� Power Apparatus&Large Appliances � O�STRiCT NO. PROCESSED BV ,/� r � �/��-,o. �+ � Size S Type HP,KW,KVA,or KVAR I D \'�Ol\C.��� Q, Lieense Num6er-`���Lic.Class`�V ____ .._.UP to 1 IncG'".... .__ ._... .. . . _ ._.__. FlNAL . ..__ .. __ . _ . . v Over 1 to 10 Incl. DATE//��� - � �Contractor-�iLZ%�'C-1�'�--Defe��--•�._. __. . _ _ . . . __ .. . .. . . .. . __._VALI _ ._ Op DA710N ❑ Over f0 t0 SO InCI. FINAL ,�,j�Yl� C) I am ezemPt under Sec. . . . . - _ Oyer 5Qto,100_Inc. __, BY �l'GUs.�'.� .. -. . . . --_-- -- w ��---- BSP.C.for lhis re2son � ' Over 100 �..� 7 n^ . � .. . � -- -Services,�Swbd.;MCC&Panelboards- .. . --�--.. -. . - - . .. .- . . . `n .. t . . .-_. ._ . . . . ._ _.-. Z # ...____ .- _ __._ ... �-Date: -� ' .. 0-200 Amp.Urder 600 V , T�" ' • ° �2 i � S'gnature -- -�-201-�1000 Amp.Under 600 V-- � � � - � -- �-- �--�� � -- � ` -.._�.� ._.__ .__. _.._..----_- - Over1000AmP.orOverB00V .. ._. _ • e � � � ;C.CL � ❑ ._..._ . '. 1 Exemption Mr Reg.Maint.Elect - ------ - .- � , _ . _ _ 1 T r ,;_ -��� �' -�����`� SINGLE FAMILY� - � ��`� � 7emp.Power Pole&Appurtenances , HOME OWNER-BUILDER�ECLARATION - -...- ..... .. ..- �.. _- ..... ... . .. .- . _. .._ .._.._ �, . ^-,- I hereby aFfirm that I am ezempt from the Contrecla's License Law Sgn wiih One Branch Circuit - 0 i.c�G - ;; -� - tor the following reason(Section 7031.5,Business and Professions-� Additional.Sign Branch Circvits,.._._.._ . ... _. _ _...----. _ .-. . . .. _._ .. Code$ ❑ I,as owner of the ro r wili do lhe vrork and the sfructure Misc:Conduits 8 Conductors_----��- --- ----�- -�- �- -- �- � ��-� . � -�.. . P Pe tY. _. . _ . __'_ _ ' is rrot intended or offe2d for sale(Section 7044,Business Other(See Complete Fee Schedu�e�_ . and Protessions Code). � ---- ---�---�__. __..-_. . .. .� _ . . ... , � - CONSTRUCTIONLENDINGAGENCY --- - - - - - � ---- -- - �- - � - - -� � -� � � . ..._ _.. ____._ _ _. . . . _ . __ .. ._ I here6y aftirm that there is a construction lending agency for the , ' performance of[he work for which this permit is issued(Sec.3097, . pERM1T FEE--���- � - - � � ��� - -(Sub-Totap. - Q 5 Civ.C.1. . _ ... ,. . . _.. _.. .._ . - __- -PLANCHECKINGFEE_..._. .___. ... . . ... _.._ _.. .._ _ • .Lender's Name /O i ,__ PERMR ISSUING FEE __ __.____ ' Lender's Address � I certify that I have read this applicafion and state that the a6rne _ TOTAL FEE / � _._... --'-'_...... . .. . . _. . „ _ _. . ._.... . . inFormation is correct.I agree to comply with a0 County ordinances � 1 and State laws regulating Electrical wiring,and here6y authorize � � 1 representatives of ihis CouMy to enter upon the above-mentioned -- � -�-� -���-"-��- � �-�� '�� � � " �� ��-� � � � . . . _. . . _ . . ._.. I tor inspection purposes. i �„�,-^ C�/s� . ___. SEE REVERSE FOR EXPLANATORY LANGUAGE .. . �✓�l�Li ---_ .. .. __ . .__. � Signature of Permittee ' Date � � - - ,,.._. : �, r�.�-,�. �,�,- , . .:.,._. ._._..���_: . . ., �--�.. ; - -�- , ,� _i., .�--'-,' -I.;- I- i-i- -I--' ! � .�,� l ; � , r"�; � , � ' � I-. i - i� �, , �,i .I t i � y,',,. � ( �, � ,_ I ` � , ' , � , . I I i ' I � , . f - �� + � %) ' � I !. ,� ,' �/ 'Y. ` '� . . It c�,j �� �� -� ( 1 s,i/��f �r�' I ( � � � � \ �f � - �!; �V I � � � j � ( �/..�' �/^ � __ - � . �� �f i`/ ' i _ i I �i�i I, _{ . - -- - �- " li ±�� �� i t � �}'� �'� .i /'�. I ,�� � � � � � �� �I� � �� � �/ ! � I i/ i� n - 1 . ����` i,�.,� � , • � �� .,. •. . i � �:'� ♦� �.� f,zp S $ v: �n �i '37 � :-a' %;' � _- •^=�.� '�%}`, ' ,� Z � "X � 7� 'r�' �...t . j I ��. �� r,�r �"/ �1 {�n � � .T�ml C ,�i, 2 m '� �� �i i� ,.._. ! I i,� i� ���� i�. 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