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1791A
WORKERS'COMPENSATIONDECtARATION ��� ���81 APPLICATION FOR ELECTRICAL PERMIT �� � � I here6y affirm rhat I have a cer�ificate of consent to self �E-� . insure,or a certtfim�e ot Workers'Compenea�ion Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFET or o cerlifi�d`copy thereof(Sec.3600,Lab.C.) ! P❑OIiCy NOv'J�COmpo�yL��U�//[./� FOR APPUCANT TO FILL IN �06 ns Certified topy is hereby furnished. �Nd. New Residential Bldgs.8�Q o�{L��� EACH NO. FEE D�RESS 3� /�/�• � Certi{ied copy is filed with the covnty b�ilding inspet- 1 8 2-Family,Sq.Ft.� 5 = 5 OCA�ITY/lj� ���/ /'3� f' depa�ment. ��/�� '^ Mulli-family Sq.Ff. NEAREST �� ,��JJ /J/`^�'/� Residential Swimming Pools CRO55 ST. �ate � Applican�^'/ / ' ""..x-2 , OWNER OR Hv� FIRM NAME CERTIFtCATE OF EXEMPTION FROM WORKERS'� Ov�lets:Rec_LigM_Sw._ ��� ;1 � COMPENSATION INSURANCE �� nooaess •(/. X vZ Thl�c�cfion n��d nof ba com lel�d if th�work Involv�d 6 Firdt 20 ���� ���� / ( P y 7otal No. CI Tel.Na. th�p�rmlt li for on�hundnd dollan(SICO)or lass.) Additional I[e�tify ihot in Iha performonce of ihe work for which Ihis q�ppp�qNTK � _ permil is issued,I shall nof emptoy ony person In any manner so as to become subjett to�he Workers'Compensotion laws. tt9hting Fixmres First 20 ADDRESS - - � Tofol No. Additionol , CIN Tel.No. Do7e eppliConl Fized Applionces Nol Over 1 HP PERMIi �1OTICE TO APPLICANT: li, afler making this Certifimle of APPLIfANT � /� � � L ,Exemplion, yoo should become sobject �o the Workers' Range_Heater�D.W._ � Compensolion provisions of ihe Lobor Code,yoo m�s�fo�th- O�nn _Dryer _W.M._ � ACDRESS � �x ���� wifh compiy with such provisions or this-permit sholl be Top _FAU —W.H.— /� /70 p. p/ � deemed revoked. CIN Q Tel.No. / � -LICENSED CONTRACTORS DECIARATION � Hood _Fan _Other_ UCENSE OR /).fl Oisp. _Room Air Cond. -- � REG.NUM6FR vL/ ClassC�� I heraby offirm�hot I om licensed under provisions of Chopler 9 y� (commencing with Secflon 7000)of Division 3 of.tha Business DISTRICT NO. PROCESSED BY �- and Profeseions Code,ond my Ncense is in full force ond effed. Power Apparoluz 8 Large Appliantes (� ( v / �Q�A , /l,� b Size 8 TyPe HP.KW.KVA,or KVAR� �� � (�\Q.\Q�Q � License Number ��� ��L� Lia Closs� FINAL Up to 1 Incl. DATE 0 �����f. �./ � Over 1 to IOlncl. �I�o� YAUCATION F— Conrracior [,//��ote � FINAL � O Over 10 l0 50 Incl. � I om exempt under Sec. Over SO fo IOO lnc. BY n- 8.8P.C.for this reason Over 100 �� Services,Sw6d.,MCC 8 Panelboords . . Date: 0-200 Amp.Under 60p V � . -�� 7�� � . Signature 201-1000 Amp.Under 600 V � � e aOve�1000 AmP.or Over 800 V . �e •2 E:emption for Reg.Maint.Elett. I • e 9�v 4 SINGLE PAMILY Temp.Power Pole 8 Appurtenances - HOME OWNER-9UILDER DECIARATION Sign with One Branth Circuit • • �9�:,J L=� �herehy affirm that I om exempt from the Controctar's Ucense qdditional$ign Branch Circuits law for the foliowing reoson(Seclfon 7031.5,Business ond � Q 9,2 2—8 B Professions Code): . ❑ I,as owner of the properry,will do the work and the Misc.Conduits 8 Conducrors . strudure is not infended or offered(or sale(Section Other(See Complete Fee Schedule)_ , � 7044,Business and Professions Code). , ' CONSTRUCTION LENDING AGENCY � I hereby affirm thal there is o consrroction lending ageocy for the performance of the work for which this permit is issued - PERMIi FEE (Sub-Total) j � (Sec.3097,Civ.C.). � - - PIAN CHECKING FEE � lender's Name � PERMIT ISSUING FEE � - � O � � lender'sAddress . � � ..� I cerfify thol I have reod this opplitation ond state thot the � TOTAL FEE . . � above informolion is corcecr.I ogree to compty wilh oll County ordinontes ond S�ote laws regulating Eledrical wiring,and - here avthorize�epresenlalives of fhis Counly to enter upon 0 ove-r*�e�tio�ed property for inspedion porp es. 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