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WORKERS'COMPENSATIONDECLARATION 76A683 ,o,a, qppLICATION FOR ELECTRICAL PERMIT � {� � I hereby affirm that I have a certificate of�wnsent to self insure, Ce-sosG or a certi�icare ot workere'Compensation Inwrance,or a certitied COUNTY OF LOS ANGELES BUILDING AND SAFETY L� . Copy there^oF(SeC.3800,Lab.C.) � - PoIiCy No`�`j.fl.��36�jmpany'�uhuSl��A� �Nh FOR APPUCANT TO FlLL IN.... . JOB 4S� � �]pU I !J C,V' ��L� ❑ �Certitied coPY is hereby furnished. . New Residential Bldgs.8�0l�y�p EACH- NO. . FEE ADORE55 � Certified copy is ti�ed�wifh the counry building in -ection 1&2•Famiy,Sq.Ft_,6�.6 LL_ 5 � — � / LOCALITY 2S ^V �o � 3 — NEAREST .. . � . depaihnent.. . � �- � � � Multi-family Sq.FL CROSS ST.���� - `�•- . . ,� /�,�� �� � Residentiai Swimming Pools Date ,���AppliC�nt , .� FlRM NAME A (�. ` / � - - CERTIFICATE OF EXEMPTION FROM WORKERS'�� . Mni� . . � COMPENSATION INSURANCE . . Outlets:Rec—L'ght_Sw.— -- :--- �� i � ADDRESS j S _- V�. y �� ,(ThIs settlon need not be compteted if ine work involved bY the 'Flrsl 20._.._, CIT el.No. permit Is far one hundred dollars($100)or less.�. Total N0. Additional - R ESR 2�0 �� I cerlify Iha�in the performa�e of.the work for which this permit _ . , i ', '� , �NGNECK� � � � �. '�� .-'- � ' APPLICAN( .. .._. ......_ _. -is issued,.l shall not�employ.arry person in arry manner so as to . - become sublect to the Workers'Compensation Laws. L'ghting Fxtures Frst 20��-�� --- ' � -ADDRESS--��---- -� -� � � ' � � ' � -� - - . Total No. Additlonal CITV- ��-� --- - � �' Tel.No. Date�� Applicant � Fixed Appliances Not Over 1 HP NOTICE:�TO�APPLICANT;Jf; after making. this Certificate ot f'ERMiT•� �� � . .Exempibn,yrou shoutd become subject to the Workers'Compensation _._ _..__Range_ Heater_ D.W. _ nPp-iCnrrT �'"'eL �CC '��C .. - - - -. _... _ .... . provisions of the Labor Code,you must forihwith comply with:awh � OvM—Ckynr_W M._ � PDDRE55 � �7 O �,provisions or this pe�mit shall be deeined re+roked. .�., . _ Top _FAU.__W.H._ .__ . ___ ______ . � � � CITY i� 1 7e1:No.s .., .,. , , LICENSED CONTRACTORS DECLARATION, . � Hood �_Fan _ O[her_ � .I hereby afiirm that I am licensed under provisions of Chapter 9 . .Disp.-- Room Air Cond,-_ uceNSE oe Gass. (commencing with Section 7000)of�Division 3 oi the Business and - aec.NUMeErt- �O S3� -C��a Professiong Code,and my license is in full forte and effect. po,,��qpparatus&Lar9e Appiiances DISTRICT NO. PROCESSE�BY _._. _ . .._ ._.. . ... ._ _ /'�.... ,/� ` ^ � � Size S Type HP,KW,KVA,or KVAR �J � '10.\o n � � � � License Number LI 9 0 0 8 3 Lic.Class C'�G � ���-�� �- -Up to 1 IncL � - ----- -"� � --- FINAL� � - - - - �- - � -� � --- - � U Over 1 To 101nc1. �A� 2�(�" VALIDATION a Contractor�IeCT(ZICA-C' oate� _ - -- O ,` Over 10 to 50 Incl. FlNAL 1- . ❑ I am exempt urrcier Sec. . Over 50 to 100 Inc. _ gy _ �U B.BP.C.for this reason Over 100 ' � p� � Services,Swbd.,MCC&Panelboa.ds� � -� ---- �� � - � - N _. _ _ �a�e �___.. _ . _ _ _ �1 1 86�� � 0-200 Amp.Under 600 V � � Signature ���--207-1000 Amp.Under 800 V- -- - �� ��-� � � � -�� � -���� � - �� . .. - _ . - - - . .. ....... Over 1000 AmP.w Oder 600 V �}-s •.• e•"2 ❑ Esemption for Reg.Maint.Elect. -.. . -. . -- - _... _ . _ . .. . .. ..._._._... . . . � e 1 2 Q 4 6 ��" -� " SINGLE FAMiLY �� ` Temp.Power Pole 8 Appurtenances HOME 04NNER-6UILDER�ECLARATION Sign wiih One BmnCh Circuit � - • ° � G b 4 6 U' I hereby alfi�m that I am exempt from the Contractor's License Law qdditional Sgn Branch Circuits ,,. for the following reason(Section�037.5.Business and Professions � -�- � - --�----�----�� - ��- Q 8 2(�-8� Code): � � � -� Misc.Conduits-B-Conductors ... ..-. ..- __ . ... .... ...__ _._. . .._.____.. ... . ._ I,as owner of the property,will do the vrork and fhe structure is no!intended or offered for sale(Section 7044,Business Other(See Comp�ete Fee Schedule)_ ► and Prolessions Codel. .._ .. . - . _. _ _.. . . .._ . . . .._. . . . .. CONSTRUCTION LENDING AGENCY � - � � - � - � �--� -�---- - � ---�-- � - - � � I hereby affirtn that there is a construclion lending ageruy for the � per}ormance of the work for which this permit is issued(Sec.3097, - �PERMIT FEE -� - -� -- - - �(Su6-Total}- S ._ . -_- . _. . .._._ .._ . _ . _ . Civ.C.1. .- .PLAN CHECKING FEE ... _ . . ..__... ..... . ___ ..._ . _ . . .. ... _ . ...._ . . Lender's Name , . PERMIT ISSUING FEE __,_._ _ __ _ , , SQ . � .. . .... .. . . . ._. __ . . . __ . . _. . . _ Lender's Address ' I certify that I have read this application and state that the a6ove TOTAL FEE . .J 2�p�y�j . . . . . . _ . _ . .... _._ . . _ . . _. . _ . information is correct.I agree to comply wilh all Cwnty adinances . and State laws regulating Electrical wiring,and hereby aNhorize 2presentatives of this Cwnty to enter upon ihe above-mentioned --� -��� � - ������ �-- � ' - � � ��-''-- � - � �-� " � �'� '-" proper for inspection purposes. .SEE REYERSE FOR EXPLANATORY LANGUpGE .. - _ � fR . . _ . _ _... __....'_-..._... a 2 Signature of Permittee Dal � - _.�.'._ �.:�.C'�_.... _.', �----=�,i r— --. --1- ;- ""__ i I.-r___..i i : ' I , ___1__I'�__, ; ;� _ i ,:- ; ,._ - 1 "_ � I-- ' � � '= i I � '� '� - � !_' �' ! l� I j� i� � ; �. �j � - .� i �-."_ i I � !-- ' ' 1�' I - � ` � � - � - � �, �' � � _ � i � � I' '� � � ' �• i j - ' ' = G I � � ' - . � ` �� . � ^' F r -I � ;_ ; . j � � _ I - � �i ...� � — -�-- � � ; , ; ; ,:� i: �—� � r :. � E I � � � � •� I �� 2 Z7 � �� Tx, �Z� � C ,-I + f, •.''� ( + i � i � (� �-' � D O -1 � � O � � , ' �_�. ! % . -! t. . �, ;.umi � -=-at 7m�.7 C'� � 2 m v ") ..5.: � '� � f , � I �" i ' , i i � ,� - � ' i o c N o � ° � i _�, ., f / .� I �' �i_� , _ _ ! , ...� ' _ z � m _ �. � ' i 1 � F' �':. ; o a ' 1 - , o � � o ! r, . 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