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WORKERS'COMPENSATIONDECLARATION 76A683 �o�g� qppLICATION FOR ELECTRICAL PERMIT {� � 1 hereby�affirm that I hava a certificafe of Consent to seH insura, CE•s06a or a certiticate ot Workers'Compensation Insuranca,or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY L� cropy thereoTf(Sec.3800,La}6�.C.� PoIiCyNo.C�l��O���v�ompany�UbUSTRI��.��Nn. FORAPPUCANTTOFILLIN . � -- JOB -�-��uu.. ��IJ ^ � CQQ , .❑ .Certified copy is hereb furnished. . _ . .:EACH NO. FEE. AODRESS �7 z V . Y . , New Residential Bldgs.& ol�s,_ S % n��!^ Z' ��� Certified bopy is filed�with the county building inspection 7 8 2-Family,Sq.FL ZS � — S LOCALITY , A b (/ . - dBpartment. .. - � r Multi-family Sq.FL — NEAHEST . CROSS ST. .Date��App�itant� � Residen[ial Swimming Pools ,"-�� � " �� OwNea Or� ^ ( __ FIRM NAME C R .CERTIFICATE OF EXEMPTION FROM WORKERS'.� ' - . � ;�,-�'. titAiL f� `� y ��COMPENSATION INSURANCE -. Outlets:Rec_light_Sw.— r�oaess 3 � RV G (This seeUon need not be eompleted tl lhe work(nvolved by lhe �rst 20 � . CIT �. � el.No.(� permit is ior one hundred dotlaro(5100)or less.) -- . Total No. Additional - US1 �sP�� � d J�'�d�� I certify that in the performance of ihe vrork tor which this permit � . _ - - pP��pNT K- �-��� . . _ is issued,I shall not employ arry person in any manner�so as to - -. � become subject to the Workers'.Compensation Laws. .� L'ghtirg Fixtures First 20---- � ADORESS-�� -.-.--��.- - . - � - � - ' . � . . Total No. Additional GTY� --�- -�- � - Tel.No. Date Applicant Fixed Appliances Not Over i HP �h NOTiCE-TO APPLICANT:.IF, aker.making this Certificate of APaLIOarli � ���. E`�C1 2� .Exemption,you should 6ecome subject to the Workers'Compensatron Range_Heate�_.�.W. _ ,provisions of thr Labor Cotle,you must�forthwith comply with such Oven_ �ryer_ W.M._ ADDRESS ' ��.� �,�4 provisions or this permit shall be deemed rewked. � � , ____7op _ FAU_ _ W.H._ � . . . . . . . CITY���UO ��a�-Te�.No.S9 i-6Y6r LICENSED CONTRACTORS DECLARATION � Hood_Fan _ Other_ ,I hereby affirm that I am licensed under prwisions of Chapter 9 LICENSE OR po (Commencing with Section 7000)01 Division�3 of the Business and ����Disp. —Room Air Cond. _-.- f7EG.NUMBER �� O U� - ��%C-��0 Professions Code;and my license is in full torte and effect. pp�r Apparatus 8 Large Appliances D�57RICT NO. PROCESSED BY License Number � I n�U 3 �`i U Size 8 Type HP,KW,KVA,or KVAR �(J ��c�1 tlr� � Lic.Class _.-_ ._UP to 7 Ind. � . �_ .. .._ .. - . ._ FINAI .�. . -' _.. .. . .-. ..Cont2ctor-���C�R�C�L�: ��. �� � . Over 1 to 10 Incl. DA�.`�-��� .VAUDATION � . .. ._ ... . . . ❑ Date � Over f0 to 50 Incl. FINAL � V I am exempt under Sec. � ,_ _. _ Over 50 to 100 Inc. ._._ gy . _ . .. _ . . .. _ Over 100 � . . . .. . . . . .. a , B.&P.G For thi9 re2son � � � - Services,Swbd.,MCC fl Panelboards � � N ..... .. . __ , ......_. __ . _. _ __ _ oate: - :1 1 8 5 A � 0-200 Amp.Under 600 V • Signaturc - 201---1000 Amp.Under 600 V � -�- �- � � � - �-� --��- -- -��.-• . e e 2- ._Q.- .- . -- .-. .-. . . .... . � .: Over 1000 AmP.or"Over 800 V .. . . . . . Exemption tar Re9.Mafnt.Elect. -- --- �-. ..-- -- .. ..--- - - � - - ---� _ � � 12h46 - SINGLE FAMILY - � -� Temp.Power Pde 6 Appurtenances. ' HOME O\NNER-BUILDER DECLARATION ��-� Sign with One Branch Circuit . ����� ��� � �� ��� � �' °���2-E+-�C 6�- �I hereby affirm that I am exempt from the Conhactor's License Law lor the foi!owing reason(Section 7031.5,Business and Professions Additional Sign Branch Circuits _ __ :_ ._ .- -�--�-. . - -__� _- ..0 8.2 6-�p �� Code�: ❑ I,as owner o11he property,wiii do the work and the structure -� "Misc.Conduits 8 Conductors � - � � � - -- � ��� - -- � --- � -�-� � � - is not intended or of(ered 1or saie(Seclion 7044,Business aher(See Complete Fee Schedule)_ ► andProfessionsCodel. --- --- ----.._�. - ..-.--.. �.. .. . . . - CONSTRUCTION LEN�ING AGENCY - � - - - - - -- -- �--- - . .. ..._._. .. . _ . ._. _.. . . . ._. " I here6y atfirm that there is a construdion lendirg agency for the performance o1�he work for which ihis permit is issued(Sec.3097,... pERMIT FEE-� --��� --� �- - � ---(Sub-Totap � S . . ...-. Civ.C.). . . ._ . .. . .._. ._ _.. _PLANCHECKINGFEE_. �__.. . .. ... _._...__.. . __. .. .._... .-- _ . _ ._ .. . - - - ----..._ Lender's Name � � ., PERMR ISSUWG FEE . __ . IO S� .... . . . . __ _ .. _ ...- - .. _. Lender's Address p � I certify ihat I bave read thls apPlication ard state ihaT the above .._ .�TAL FEE . z�p• r � �- � - - --- . _. .__ __.._ _. _ . _ .... _.... .- - �--. . information is correct.I agree to comply with all County ordinances �� `� antl State laws reguiating Electrical wiring,arrcl hereby aulhorize representatives of this County to enter upon the above-mentaned - � - �- � - - � � �- � �� �- ��� � �-��- � - ��� - ��- � �� � �'��� - propert for inspection purpases. . _ _._. .SEE REVERSE FOR E%PLANATORY.LANGUAGE ..__ . . � --- _. .. _ _. . . .. . � � �� 8� Sign ture of Permittee D te . , . . . �".�. _..,!_`_� ., �.°. +.-r----iJ �-- -i -': --- i- ---__i---� .--i-_ � '---I--�--� . i t� i �^ I, _ I � ; I i I �" �" + �� � i � !' � � -. �- I-- �' ,I:. ; I; i i I � _ ; i;- i.. i i � � i � I i -_ � i� `, , i "� i ; , i { j, � _ _ !� � , � ._ � � - � _ � ; � ' � ._ ' ; i �.. � � ; j � ' i + i I- I ! , I t'� I ! 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