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� � WORKERS'COMPENSAllONOECLARATION 78A683 +0�8, qppLICATION FOR ELECTRICAL PERMIT {� � I hereby affirm ihat I have a certifiCate ol consent to self insure, CE-8o6G or a certificate oI Workers'Compensatbn Insurance,or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY u CoPy thereof(Sec.3800.Lab.C.) Po�tcy N��901�s'3(>3�mpam,l v D u ST�t(ll. �u'D i0H APPUCAFIT t0 FIIL IN. . JOB �3� �� r�a���� �2 � Certifled copy is hereby turnished... ., , , New Residential Bldgs.8 EACH. NO. . ._FEE_ AODPE55 � Certified copy is-filed with the county buildirg inspection 1&2-Family,Sq.Ff:�� g — `� LOCALITY--`R `�12 S��-U �I� 3 � : department �,: :�. . /� -�) Mulli-(amily Sq.Ft. — weaeesT . . � ��,�f,W�., Residential Swimmin Poois cROSS si. � 0.�te 30 ¢��Applicant '��`-K f 9 OwNER OR flRM NAME C F} � .CERTIFICATE OF EXEMPTION FROM WORKERS' p�tlets Rec—L'ght—Sw.� � ' MAII . �, � COMPENSATION INSURANCE � � � � - � �-- � ADDFESS� S� W U C �� (This sectbn nead not be completed H Ihe work involved by the ' Frst 2 0 permit fs tor one hundred doltars($100)w less.), Total No. Additional- CIT � �- �.. 2 �Tel.No.$S�_00 I certi(y that in�he performanCe Ot the wOfk lof WhiCh�hig p2r�nit .. . . ppp���pM K _. is issue0,I shall rrot empioy nry person in any manner so as to � � - — become subject to the Workers'Compensation Laws.. L'ghting Fxtures Frst 20 - ADDRESS ��-- - . � - � - � Additional � �� ' � - � � � '' � � � - � Totai No. CITY � �- -- Tel.No. �Date . . .. ..ApPlicant �- � - Fxed ADPliances Not Over 1 HP pE�Mii � . .' i� :NOTICE TO APPLICANT:� if,-after.making this,Certificate Of qppV�M , � �L ` �CTQ�� Ezemption,you should become subject to the Workers'Compensation .. ....Range—Heater_D.W. _ . . _ -_ . -.-. ��-provisions of the Labor Code,you must forthwith comply with such ' Oven_ Dryer_W.M._ AOpRESS b � provisions or this peimit shall be deemed rewked.- . . . Top- _.FAU._-W.H._- . -__ .. . .�� LICENSEDCANTRACTORSDECLARATION Hood_Fan — Other— . ��� o� l70 � T�.N�.$9J_6y6! �I hereby affirm that 1 am licensed under provisions of Ghapter 9 uCENSE oR (commencirg with Section 7000)01 Division 3 of the Business and -Disp. �—�Room Air Cond. _� - � - ��� �"- qEG.NUMeER' OO g 3 qass.C�0 Rofessions Code,and rtry license is in full forca and effect. p�,nr Apparatus&Large Appliante5 . -.. . _. _ ._ DiSiRiCT NO. /'� PROCESSED BY � � Lieense Number� l�� 0 3 C-f 0 Size 8 Type HP,KW,KVA,or KVAR {V �_ 1 d{� � O Lb.Class � Up to 1 Incl. FINAL J(�/ �� p Over 1 to 701nc1. � DATE�Z V CJ/ VAUDATON.. � ...EIECTR�C-r+L � Date�2� ._. ... . ... .. . . . _ . ConiraCtor Y pver 10 fo 50 Incl. � U FlNAL ❑_ I am exemPt under SeC. . . � ., ��. . -.. _. � Over 50 to 100 Inc..._ BY-. . ._ .� ._:. . �_..._. .. W B.&P.C.for this reason Over 100 ` � - oate: "._ services,swbd..Mcc a Panerooaros--. . . _. -_ . �. .. _.___ .. _.. �1 1 7,,7 A� z I. 0-200 Amp.Under 600 V Signature 307-1000 Amp.Under 600 V--- � � '- � � - � � • e e -� � Over 7000 Amp.or Over 600 V �• •2 � Exemption for Reg.Maint.Elect. . -. .. - . . . . . . ..... . .. . ... .-- - .. � a •'��(�O �- � � -SINGLE FAMtLY- �- -� Temp.Power Pole d Appurtenances ._ . ., HOME OWNER-BUILDEf1 DECLARATION Sign wiih One Brench Circuit - - - - � � 7{?`��'' - I hereby aifirm Ihat I am exempt from the Contracto�'s License Law for the fotlowirn�reason ISection T031.5,Business and Professions � Additional Sgn Branch Circuits- �� � �- � --� - �� '0 El Ctl--8,g" Code�: � � �Misc."Conduits S Conductors-" � � -- - �- ��-- ---�- --� - � � ' I,as owner oi the property,will do the�work and the structure � is not intended or olfered(or saie(Seotion 704a,Business �Other(See Complete Fee Schedule)_ � . . _ arid Professions CoAe).. - . GONSTRUCTION LENOING AGENCY -�-- --- --- �� - ' � � ' -� � I hereby affirm th2i Ihere is a construction lendirg agency for the r� performance of the work for which this permit is issued(Sec.3097, �- pERMR FEE � -� � - -� --- (Sub-Total)-� -�-- - -�-- �- ���� ���� - �- � O Civ.CJ. � � PLAN CHECKWG FEE .... . ..- . . ... - _ - - .... .. . . . . .. Lender's Name - PERMR ISSUING FEE . ... . .. . . . ' . O S -�-- � � Lender's Address - � ' /'� I certify that I have mad this applieation and state[hat the above . TO7AL FEE _ .. ._ . .. . _ . - . , 7,J'.9 . _ - _... ..._.... . ._. _.. infamation is corred.I agree to compy with all Counry ordinances antl Stale laws reguiating Eiectrical wiring,arW hereby authorize_, . , , � _. _. .. ._ . . .... _.._. . . . . . representatives of this County to enter upon the above-mentbned � �� � - � �-� �� �� � � � prope y for InspecYmn purpo e _... -�SEE REVERSE FOR E%PLANATORY LANGUAGE - .-- . - �, h . __.. ._ . .. . . d Signature ot Permittee ate IY:�:,_ ... :.�_�: r U�:.... 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