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WORKERS'COMPENSATIONDECLARATION 76A663 ,o�B� rqppLICATION FOR ELECTRICAL PERMIT .�� � I hereby 3ffirm that I have a certificate of wnsent to self insure, ce-eoeG . or a certificate of Workers'Compensation msurance,or a cert�tied - COUNTY OF LOS ANGELES BUILDING AND SAFETY copy thereot(Sec.3800.Lab.C.) ,` /� PolicyN�;19o{�C363Comparry�N�Ug�Rtn� I��� FORAPVLICANTTOFILLIN - " J00 ❑ Certified Copy is hereby furnished. EACH� NO. FEE ADDRESS � V� 2 (� � New Residential 81dgs.8 ols �"Certified copy is filetl with the county building inspection 1 8 2-Family;Sq.Ft.�r2 � � — S LOCALR L�/2 S� _V O % � - -department: ��:�� � - _C Mu�ti-famity Sq.Ft. — NEnaeSi . 30 $'� � Residential Swimming Pools C�OSS Sr. Date�Applicant � OVJNEROR ` flRM NAME � CEFiTIFICATE OF EXEMPTION FROM WORKERS' ' � -"' ' , �„�q�� .� Ou[lets:Rec—Light_Sw.— . I� - - COMPENSATION INSURANCE ;�� �„ � � � -� AD�RESS��S � UC ! �, (This sectlon need not be eompleled M the work Involved by the Frst 20 . Totai No. AdditiOndl � . CR Tel.No.Q�- f �permll Is tor one hundred dollars(5100)w less.). ST �A p j00 � iI certify that in the performance of the work tor which lhis permit PLAN CHECK _� Vg iSSued 1 Shall rrot employ arty person in afry manoer so as to , A��M - become sublect to ihe Workers'Compensation Laws. , L'ghting Fixfures First 20�-�- ADDRESS - � Adtlitional � � - � � - �� " � � Total No. CITY- - � � ' ' Tel.No. Dat=_ Applicant � ' � Flxed Appliances Not Ovet 1 HP NOi10E. TO APPLICANT: If, after makirg_this Certificate of ��M17" C /'` �` �1�C'T�IC Exemptan,you shauld 6ecome subject to tho VJorkers'Compensatbn _ .. Range_Heater_ D.W. _ ����'�T 2LT l � .�.�������s M t.he�r,...G.no y=�;.,_��r�..�.,;^•h co^.:f.•:.^th^:ch D:^n_C'1�cr_1H."._ ACCRESS , Cj_ \�Ox ,pmvisions or this permit shall be deemed revoked. ,. . _ . .._.Top —FAU _.W.H._. ._ -- _ . -- -- Cm,�`1 t�� �0(� Tel.No��-�j yb� .LICENSED CANTRACTOF75 DECLARATION Hood_Fan _ Olher_ Tt s �I hvreby.affirm that I am lice�sed under provisions of.Chapter 9 -Disp. _Room-Air Cond. _ uCENSE OR q p�} (commencing with Section 7000)of Division 3 of the Business and REG.NUMBER (0�(„) J ' C�ss�� Q Pf0(BSSiOnS GOdB,afld Rry IiCenSO IS ir1 full folce and effeCL DISTRICT NO. PRpCESSED BY _ . - �Power-Apparatus&large Appliances - _.. . . _� � , . ��`o�� � p. ¢ Size&T pe HP,KW,KVA,or KVAR Q License Number L�!�DO � Lic.qass �-�� - � � Y Up to 7 Incl. - � - " ' FlNAL /// - - �+ - E� TR�I�! �-� - �r 110 t0lncl. OATE /7 „�G � �c �_ v VALIDATION �Coritractor Date � � � - OO Owr 10 to 501nd. FlNAL ❑_.I am ezempt under Sec. - - � _ Over 50 to 100 Inc. gy . .. . __ _ . _ . yV,� 8.8P.C.for this reason Over 100 � 6. . . . . . _ . �.. Scrvkes,�Swbd..MCC S Panelboards".. .. .. . . . —- -�---. --. . Z - Date:- - 0-200 Amp.Under 600 V �1 1 5 6 A — Signature - �201-1000 Amp.Under 600 V � --- �- "- � � - - - -- ..._._ ... __._. . _ . . .._. #� �� . .2_ ❑ � Ove�1000 Amp.or Over 600 V Exemption tor Reo.MaiM.Elect -�- - -� ��-�-��� _.... _ I � 1i218 � - �� SWGLE PAMILY - - . . _Temp.Power Pole 8 Appurtenances HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit �• • � � 2� o i_i I he�eby affirm thaf I am exempt from the Conhactors Lkense Law Additional Sign Branch Cir�vits for the followin9 reason�Section 703L5,Busir�ess arM Prolessipns � "�� - �-"--- �� O��b_8-8� Code): Misc.Conduits&Conductors- " - -- --� � ' � ' � - - � - - - -- � � ❑ I,as owner of the pmperty,will do the work and the structure . is rrot intended or ofFered for sate�Section 7044.Business Other(See Complete Fee Schedulel_ ► .... ____ . . . . . .. . and Professions Code). -� - � - CONSTRUCTION LENOING AGENCY -- -�-�� � -� I hereby affrm[hat there is a construction Iendirg a9ency tor the performance of the vrork tor which this pertnit is issued(Sec.3097, -- pERM1T FEE�- � - � - � � �(Sub-Totaq- ('� � � �- �� �� � - � - Civ.C.). � -PLAN CHECK�NG FEE -- -� - � . . .. .. _ _ . _. , Lender's Name -� PERMIT ISSUING FEE ._. , . . ... r D- SD--�_ -- -.- . . . _ _ .. . _ . . . Lender's Address I certify ih2t I have read this application and State ihat the above --. .TOTAL FEE .. _. .. .. _ . .! �a•� . - � - .- in(ormafron is corretl.I agree to comply with all County ordinanees . � arM State lavrs regulating Elechicai Wirirg,and hereby authorixe � . . ___ . ._.._ . .. . . .,.. . . ... . . ... . ... . representatives of this County to enter upon the above-mentioned " �"� �� � � prop rty for inspe tion purpos s. �-, �-- �� SEE FEVERSE FOR EXPLANATORY LANGUAGE - - _ . _ � _ _, 22 Signature ol Permit ee 9�e 1..�--5� -'--' j'^ � � " � � S L/� r_-_ , _... _ _�.. . _ � . -... . . � _ f` I' ' ` �.._._I_ _I_ .'r I=..I I� ~�- I.�� , . !.` ` I . I ( i • i_'-i i i; ; J�1 - _ - i i� '� , � � ;= � . i` - ! �� ; � � � , ! � ': I !� � ; !=- I ; '� - � � r �I i . "� � i : �. - � ! _ 1` ; I. _ ' �'. � � � � , � ,� ; , �, , , � ' k` ;-. , t- �`� ,z: _ r- jf - -'; �i� '_ , � i � �,., i-. i ?` i,- ! i.; � • j t i � 'i�- j" _. , �'_ '_ . � ;: .-'.'�� ! 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