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1787A
. WORKERS'COMPENSATIONDECLARATION 76A683 ,o�e, AppLICATION FOR ELECTRICAL PERMIT /7 � I here6y affirm that I have a certificate of consent to selt Insure, Ce-eOSG or a certiticate ot Workers'Compensation Insurance,or a certitied COUNTY OF LOS ANGELES BUILDING AND SAFET � copy thereot�(�Syec.�3�8�00,L-�ab.C.� - Policy N�/�L,71L�1L�3��Company�y�US?7t/�_ FOR APPLICANT TO FlLL IN'- JOB /' ❑ AODRESS (Q� R I�� EACH NO. fEE Certified cnpy is hereby furnished. New Residential Bldgs.8 Poo LOCALIT L/ J /�., � Certified croPY is filed�with the countY buiiairg insPection 1 d 2-Family,Sp.Ft.�� S — � ��7� /�Gf/ � NEAREST n � � de� en. . �" � � � Multi-family Sq.Ft. Caoss SL - � . �(/ � ��/T yn`,�(7 Residentlal Swimming Pools Owt�ER oR Data , ApplieaniE��vc.F , , flRMNAME /YQ� � CERTIFlCATE OF EXEMPTION FROM WORKERS'- ' MAIL - �-��- COMPENSATION INSURANCE �. Outlets Rec—Li9ht_Sw.— � . ppoRESS •�. ..��a (This seclbn need not be eompleted H the work Involved by lha Flrst 20 permit la fw one hundred dollara($100)or IesaJ . � 7otal No. Additional CI �N ���'�a Tel.No.6��[�j . �I wrtify that in tha performance of the work lor wh�h this permit . PLAN CHECK � Is issued,I shail rrot empby arty person in am/manner so as to A��M _ becortre subject to the Workers Compensation Laws. L'ghtirg Fixtures Rrst 20 � ADDRESS � - � ' ' - '" ''� ' Total No. Additionat qTY' � -� Tel.No. Date -�� -�Applicant��-- � � � � Fxed Apptiances No1 Over t HP PEFMI7 �a P'"'QE.TO;APPLICANT: If,- after makinq this Certificate of ��M /// ��� L 1'tion,you shouM become subiect to the V✓orkers Compensation . Rarge_Heater_D.W. _ . � pro�sions of the Labor Cpde,you must forthwith Comply with suCh Oven_Dryer_W.M._ AODRESS ,/�,�x ���/ . -provisivns or this permit shal�be deemed rewked. . _. . Top _FAU-_W.H._ �+� ,�p CITY �/t,/(� �/�'d _.Tel.N d 7���� LICENSED CONTRACTORS DECLARATION �� Hood—Fan _Other_ - I�hereby affirm that 1 am licensed under provisions oT Chapter 9. - � Disp.�—Room Air Cond. -_ t10ENSE OR �� . ��s/�'r,. � (commencirg with Section7000)ot Division 3 of the Business and RE6.NUM9Efl L ��� PfOfB3510113 GOdO,afld Rry IiCBf150 IS in(ull fOfCO dfld eff2Gt. . PpWyf ApparatuS 8�fgC/ippli3lIC04 , _ DISiRIGT NO. PF70CESSED BY License Number /��Lic.Class C�d Size 8 Type HP,KW,KVA,or KVAR O 1�\R\O(�e O Up to 7 Irxl. FINAL �7 p � �,�/ L� Over 1 to 101nc1. �A� Z`. )—E VALIDATION -�Con�iacta����Cd'7`^ Date� Over 7 D to 50 IncL FINAL V _❑ 1 am exempt under Sec. . Over 50 to 100 Inc. . gy . . . . . w B&P.C.for this reason Over 100 � --.. . . _ _ .. _.. . . , .. . _ Ser6ices,Swbd.,MCC 8 Panelboards. . ". � .. _ .. .. . . . . . . Z - Oate: 0-200 Amp.Under 600 V - � � Signature �- 201-1000 Amp.Under 800 V - � - � . z 1 7&7 A . � � �- �-� � �� � � � � Over 1000 Amp.or Over 600 V . �. : . e e 2 � Exemption for Reg.MainL Elect. - - �- ' -- �- -� �� � -- �- SINGLE FAMILY� -- -��� Temp.Power Po!e 8 Appurtenzrr_es � . .9G,34 HOME OWNER-BUILDER DECLAR4TION Sign with One Branoh Circuit . . e i = I �y affirm that I am exempt from the Contractors License Law °����� f�...�e following reason(Section 7037.5,Business and Professions Additional Sgn&anch Circuits code>: 0 9.2 2—S 8 - - A�Tsa Conduits s Conductors . . . -_ . . . . _ _. ❑ I,as owner of the Droperty,will do the vrork and tha structure is not intended or offered for sale(Section 7044,Business a��.1See Complete Fee Schedule)_ , and Protessions Cotle). CONSTRUCTION LENDING AGENCY � - ' �� --- I hereby affirm that there is a constructbn lendirg agency for the � performance of the work for which this permit is issued�Sec.3097, pERMR FEE - � �� �- - 1�6dotal) � -� - - - - Civ.C.). • PLAN CHECKING FEE �- � -- - � � � � � - �- Lender's Name /� �- PERMR ISSUING FEE�� � � � - � . Lender's P,ddress p I� I certity that I have read this appl'kation and state that ihe above � TOTAL FEE _ _ .. . . L . . - . information is correct.I agree to comply with all County ordinances and State laws regulating Electrical wiring,and hereby autMrize _ _ , , , � _ __ . , _ � representativzs of this County to enter upon the above-mentioned . prop� y for inspectbn purposes. _ ._ SEE REVERSE POR EXPLANQTORY LANGUAGE � � �. . . . . . .. . ../ � �/�� Si9nature of Permittee Date , .. . � --- . i: ... :_ , . ... . , ----- - '- .' `,._' _ 1_.. .I�,_. .__ -I --1 _. , i � � �� I ' � I' ;I I 1`, :rl I I . !� . ,, �. . �. i ' � `, �. � � �� I � � . - � � . . . � •�. ,. . , . i � i •. i ' ;;,� . . _' , ; _ , ' '" ; , , . �. : , - - . _ .. ,.� . . . , '. � 2 T C 'O T' '� 3]� C -� 1,. _ , . � ,`r .., p Z -1 O '�C � O Zv 'Ri ,� . /• -f _ C � . 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