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1778A (10)
WORKERS'COMPENSATIONDECLARATION � 76nse3 +o�e� AppLICATION FOR ELECTRICAL PERMIT `��� . I hereby affirm that I have a certificate of consent to self insure, ce-soe� � a a certifKate oi workers'Compensatbn Insurance,or a certified COUNTY OF LoS ANGELES BUILDING AND SAFETY copy tfiere(p����S�/�,C/3�800,La6.C.) /�n �y� �/ POIiCy NO-�//�/V��mpa��/V UU 7//�-�/7 L+ FOfl APPLICAM TO FlLL IN . JOB /_ nN ❑ .Certified copy fs hereby furnished. , , �1Vp• New Residential Bldgs.8 Poolj.���J� EACH NO. FEE AooaEss (/� r� � Certified copy is filed with the ounty buiWing inspection 1 8 2•Famity,Sq.FL�(� � — S LOCALITY 2 �— 9 �c�r ni. - �, MOltl-(eflllly Sq.F�. — NEAREST ���Q� CFOSS ST. ..08I0--�APPIiC011t vCY""— RBSidOnliel SwimRlill9 PoDls OK'NER OR � ' -' FIRM NAME � CEHTIFICATE OF EXEMPTION FROM WORKERS' putlets:Rec—Light_Sw.—•�� ' � Ma� - � � � COMPENSATION INSURANCE �� • �' ' qooaess .�. (This aectbn need not be completed if tAe work Involved 6y[he Flrst 20 permil la for one hundrad dollara($/00)or Iesa.J. . , Total No. Addilional C N�.����, Tet.No. 7 I eertify that in the performance of[he work for whieh this permit _ Pi.aN CHECK is issued.I shal�rrot employ arry pereon in airy manner so as to � AP��AM become subject to the Workers'Compensation Laws.. . . . Lightirg Fixtures First 20�- ADDRESS — � - � � - � - � � Total No. . �itanal Date �Appl'�cant - � - CITY Tel.No. Fxed Appliances Not Over 1 HP PERMIT / . NOTICE TO APPLICANT: If, aNer makirg this Certificate of APPLiCANT �������e�� ��'Z� L Exemption,}rou should become subject to the Workers'Compensatbn ._ . Rarge_Heater_ D.W. _ �.provisions of the Labor Code,you must forihwith comply with such Oven—Dryer_ W.M._ ADDRESS x �/ �provisions o LICENSED COaINTRACTO S 0 CLARATION �� � Top _FAU _-W.H._ . . . . � - --. ��T l�U �Q/�9� �Tel.N�9�6�y/ . Hood_Fan _Other_ / /� I hereby affirm that I am licensed under provisions of Chapter 9 .. - Disp. —Room Air Cond.� _ uCENSE oR q.y�� r/� 1 (Commencifg With SeCti0f1 7000)0}DivISi00 3 0(�he Bu5ine55 afld REG.NUMOER �(/ CiassL � PfOfe55i0n5 COdB,afld RYy IiCEn58 i5 ifl iUll}OfCe and 2f(PCL � DIS7A�CT NO. PfiOCE55ED 6Y } Power Apparatus 8 Large Appliances . r Size&Type HP,KW,KVA,or KVAR v � � (� Q License Number_�lic.Class C�� - . . UP to 1 InCL � FlNAL 7�J ._ .. _. V ������ � � � Wer 110 101ncL �A�./ Z/ Q 9 VALIDATION � Contractor Date Over 10 to 50 Incl. � � FlNAL V _ I am exempt uMer Sec. Over 50 to 100 Inc. . gy . `�1 W BSP.C.for this reason Over 100 " N .._ . .. . . -Services.Swbd.�MCC&Paneltioards � , � � - � -- - �� - -��� -� Z -� �Date:� 0-200 Amp.Under 600 V -' Signature �� � ��201-1000 Amp.Under 600 V -- - � �� ' � � - � -� - Over f OD0 Amp.or Over 600 V - ❑ Ezemption for Reg.Maint.Elect. � ---�- - - � �� 7 Z S r� - � - 5!NGLE FAld!LY � � � � � Temp.Power Pole 8 Appurienances r�r� • . •� HOME OWNER•B111L�ER DECLARATION Sign with One Branch Circuit • o 1 here6y atfirm that I am exempt from the Contractor's License Law � . .�,� q(� tor the following reason(Sedion 703L5,Business and Professions Additional Sgn Branch Circuits � . ... _ . coae): • o <S 1,9 4� ❑ I,as owner ol the Droperry,will do the vrork and the structuro Misa Conduits&Conductors . � - � - is not intended or olfered for sale(Section 7044,Business Other(See Complete Fee ScheduleJ_ , 0 9,2 2—8 8 and Professions Code). � � � - � �� � � CONSTRUCTION LENDING AGENCY �� - � - � � � � I hereby aflirm that there is a construdion lending agency for the performance of the work for which this permit is issued(Sec.3097.� � �pERMR FEE � � � (�b-Totap - - �j - � Civ.C.). PLAN CHECKING FEE - - -- . . - . , . Lender's Name PERMIT ISSUING FEE � -- - (, . _ .. _ .., Lenders Address �/�� . . . . . .. . I certi(y ihat I have read this application and state that the above TOTAL FEE . , _ . information is eorrect.I a9ree to compty with all County ordinances and State lavrs reguiating EleMrical wiring,and herehy authorize , . � representatives ot this County to enter upon tha above-mentioned � -� - � � � prope for inspection purposes. �� �� �j��� -- SEE REVERSE FOR EXPLANATORY LANGUAGE - . . . . lAn_.J� �lC/J../' Signature of Permittee Date I;';; ,'e`; '"" '_�i;: . .._-----� I . �` '/ .. I.._... .,_. ._ - -, ...'..-,. _.._, . �.. � � i� � i � �, !� � � � � ' , : � � ., i y. \ i . - I �. , , . �l� . ' , ; � . I , ,� ' . , t, �.. I , . `\ , � i . � ! �' t 'j � , . . . , , . t� , � . , . � _ _._ ' . - . _ i` . . a/ .. .� ; ' � ' '- �r , - � . . _.. � o , . � p z �m .. .. : •: Z T b T 71 C � . � / , ,�. 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