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1785A (10)
WORKERS'COMPENSATIONDECLARATION 76A663 ,o,e, pppLICATION FOR ELECTRICAL PERMI �� {� I here6y aftirm that I have a certitiCate o(consen[to setl insure, c68osG or a cehiticate oT Workers'Compensation Insurance,or a certified COUNTY OF LOS ANGELES BUILDING AND SAFE u cody 1Be of Sec.�3"800.Lab.C.) �{�n�� PoIiCy N.� �/V Cpmparry�'"��T�7X�/��- FOR APPLICANT TO flLL IN - J09 ♦\ ❑ Certified copy is hereby fumtshed. /N�. EACH NO. ..FEE ADORess D�v /L . New Residential Bldgs.&Po - � Certified'copy is filed with the ounty buildirg inspection 1&2-Family,Sq.Ft. S — $ LOCALIT � �� �Q rtme t. , Multi-family Sq,Ft. — NEARESi. � ' �� Residenttal Swimming Poo1s CttOss ST. 'Date Applicant OLNNER OR �CERTIFICATE OF EXEMPTION FROM WORKERS' -.. - FlaM Nnht � - COMPENSATION INSURANCE ��ets:Rec—Light—Sw.— '� •���� � • DDRESS (This aectbn need not be tompleted It the work Involved by the First 20 � permit is for one hundred dollars(5100)or lesa.) . Total No. Additional CIT � ��� Tel.No. � I certiry that in lhe pertormance of the vrork for which this permit _ Pu+N CHeC APPLJCANT - is issued,I sha�l rrot empby arry person in arry manner so as to - become subject fo the Workers'Compensation Laws. L'ghting Flx[ures Frst 20 AD�RE55 - ' � Total No. Addilional � � Date ApWicant CITV Tel.No. . Fixed Appliances Not Over 1 HP PERMIT 7 ��,Z,�J� NOTICE TO APPLICANT: if, after making this Certificate of / Exemption,}rou should become su6ject to the Workers'Compensation Ran9e_ Heater_D.W. _ n�a�-icAr'rT provisions ot the labor Code,}rou mu5t forihwith comply„with such Oven_ Dryer_W.M._ � ADDRES ` �j// � � - provisions or ihis permit shall be deemed rewked. � Top _ FAU _W.H._ • /� �f� Te�.No. 9/�y�j � LICENSED CANTRACTORS DECLARATION Hood_ Fan _Olher_ � NU %I I here6y alfirm ihat 1 am licensed under provisions of Chapter 9 Disp. _�Room Air Cord. _ uCENSE Oa � . (commencing with Section 700D)01 Division 3 of the Business and REG.NUMBEFi �elas Professions Code,and rtry license is in full foree and elfect. aStaiCr No. pROCESSEo BY � Power Apparetus 8 Large Appliances �./�q� � Size 8 Type HP,KW,KVA,or KVAR 1 � �p`O n�. � Licensa Number /(/V Lic.Class� � - Up to 1 IncL � FINAL - /� � U ,�/�7� � Over 1 to 101nc1. DATE / z7�j VALIDAl10N_. . � ContractorS�LC y,�-�C� �ate - � � -� � � � - � _ OO Over 10 to 50 Incl. FINAL/�� 2� V ❑ I am exempt onder Sea ___ _ Over 50 fo 100 Inc. gy /��j�/,/�' .. . W _ / �%/7 8.8P.C.toi this reason Over 100 / y� - Servkes,Swbd.,MCC S Panelboards � � - � - - - _ ... _ Z � Date: 0-200 Amp.Under 600 V Signature � 201-1000 Amp.UrMer 800 V - . . �P� 7��A . ❑ � �- - � � Over 1000 Amp.or Over 600 V Ezemption}or Reg.MainL Elect. . .,__. , _ _______ _ __ . (�• e e e •2 ���- � - � S�NGLE FAMILY � - � Temp.Power Pole d Appurtenances . � � • •9[�,�(� HOME ONlNER-BUILDER DECLARATION � �Sign with Dne Branch Circuit � -� � - "- - "'"��'" � -��� I hereby affirm that I am ezempt 1rom the Contracrors License Law � � „p�; �{4� for t�e following reason(SeMion 7037.5,Business and Protessions Additional Sign Branch Cirwits � codel: 0 9.2 2—8 8 ❑ I,as owne�ol the m er Misa Condui�s 8 Condudors- � . ., .. . . . p p ty,wi�l do the work and the structure pther Sea Com I - is not intended or offered for sale(Section 7044,Business I Pete Fee Schedule)_ . and Professions Code). �� - " � � - � - -� � ---- � � � � - CONSTRUCTION LENDING AGENCY � - - - � � . I hereby affirm thaf there is a construction lending ageney for the pertormance of the work for which this permit is issued(Sec.3097,..._ pERMIT FEE �-� -- � � � � (Subdotal) � Civ.C.l. . . . ' . . .. PLAN CHECKING FEE . .. .. . __.__ � _ Lentlers Name /'l � � PERMR ISSUING FEE �� Lender's Address .� � � - - - 1 certify that I have read this application and state that the above TOTAL FEE information is correet.I agree to comply with all County ordinances- � � � � � `� --- and State laws regulating Electricat wiring,and hereby authodze . representatives of ihis County to enter upon the above-mentioned- - �� - � - ' " � � - � �- �- - - ---��- -- - . � p�pe(�j tor inspecti��� .1�� ,_SEE REVERSE FOR EXPLANATORY LANGUAGE . / Signature of Permittee Date - . . � . - . , . :' . �. .., ' ��... . ----„' , ;. ^ .._.i ; ---._... �I. ...._ '..._ . . i i � r � i . � . ,i`•. , ,t .� I . { , ' . I _ _ � . . I � i.. _ ' � - ;�� �..� - . , . + � . � . �<: E ( ' ' ' �, . . �i - �i r ,•% � . , . � ��. / � . . �. , � 1 ' , 1 �� � .. � ' ; � '// ` �. , ��_� .. 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