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WORKERS'COMPENSATIONDECLARATION 78A683 +o�e� APPLICATION FOR ELECTRICAL PERMIT � I I here6y•atFirm[hat I have a certificale ot consent to SB�f inSUrC, CE-806G oi a certificate of Workers compensat'an�nsurance,or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY ' � capy them�(of(Sec.380�0y.Lab.C.) 1��, 1 � POIiCy No`��Q����b�pmpyrjy�A�OU Sl K�I�L 1 N�� FOR APPLICANT 70 FlLL IN � " � � �OB � ^� �^ ❑ ,Certif"�ed copy is he�ehy furnished. , EACH N0. FEE ADDRESS S u � �l\6� v� - . , ��� � New Residential Btdgs&Pool }� / � '� Certified copy is filed with-the�county�huiiding inspection 1 8 2-Family,Sq.FL �� �� — g .S LOCALITY , a S7 -V l-dT�f - - dEp ime L ' �� �-- � . � ..� Multi-(amiry Sq.FL — NEAREST_ . _ . . -q � ' � � Residential Swimming Pools � -- � CROSS ST. Da{9___��AppliGanl OWNEROfl� `� � , FIRM NAME CERTIFICA7E:OF EXEMPTION FROM WORKERS ��: Outlets Rec_Light_Sw-- " ,,^�'' �� ^^°�� � I$1 C f f � - COMPENSATION INSl1RANCE --�' - � � , � � • � ADDRESS .(This settlon need not be compleled N the work involved by the -Frst 20.� permit ie for one hundred doliars($100)w Iess.J, . Totat No. Add'Rionz�� CITIC b � 2b ei.No. ���00 I certify that in the perforrttance of ihe work}or which this permit ' � PLnN CHECK - , . � �..'. .' AM'LICANT is issued,I shati not employ�arry person in arry manner so as to --�� — become subjed to the Wrnkers'Compensation Laws. . , � Lighting Fixtures Frst 20 - ADDRESS - -- - ' . . ... . . , . . . .. �� Addilbnal . . . � '' � �- �� Total No. � CITY .. .-._. .-... .. . Tel.No. Date Applicant � -� � ' ' Fixed Appliances Not Over 1 HP :NOTICE,TO�APPLICANT: If,-efter�makirg:this�,Certificate ol PERMR � C -� �Exemption,you shouW 6ecome subject to lhe Workers'Compensatbn . _ Range_.Heater_D.W. _� A�iCnnrT �� �,t C� �� �provisiong 01 the Labor Code,�you must forthwith compN with such Oven_Dryer_W.M._ � ADORESS � . -provisions or[his permit shali be deemed rewked.. ;,. . _..Top -_FAU _ W.H._ . . - . - � ��`, �' 1, p 7e1:No.� - _6 6 ,LICENSED COPlTRACTORS DECIARATION � Hood_fan _ Olher_ C! I here0y affirm that I am lieensed under provisions.of Chapter�3 �Disp. _�Room Air Cond.-_ uCENSE OR (commencing with Section 70D01 of Division 3 of the Business and - REG.NUMBER�- QO 3���� �� CWss. C`r � Prof23Si0n3 COdE,end iTy IiCenSe i5 in lull}arce arid effect. qSTRICT NO. PfiOCE55ED BY Power-Apparatus 8 Large Appliances �� � � _ � q Q ����y Size&Type HP,KW,KVA,or KVAR p� �t�-C Q License Number � !��0 � Lic.Class J✓ - �- � - � Up to t Incl.- � - � FlNAL � - ---- - � � �� v Over 1 to 101nc1. DATE/// � Coniracior�I E'�TK�CA L�"�- Date��_ . - . .. . - f VALIDATION . 0 Over 10 to 50 Incl. FlNAL � ❑ . I am exempt under.Sec. ' � --. Over 50 to 1001�.__ . BY- _. ,- -_, -._ - �_ - . .. . _ W . 8.8P.C.for this reasan Over 100 p. � -. .Services.Swbd..MCC 8 Panelboards-.... ....- . .". . - . . � . . _. .. . _. � .. - . . ._ Z. ��-Date: 0-200 Amp,UMer 600 V . � � Signature � - 201-1000 Amp.Under 600 V---- ` - - � �- '__ _._--.__ . .. .. - Over�000 nmp.or Over 60o v z 1 1 7 b A � Exemption for Re9�Malnt.Elect. �� � - - � � � �-- .. _ . : _.......... � �• • • • •'� . - �SINGLE FA�dILY� � �� . Temp.Power.Pole 8 Appuitenances.. HOME OWNER-BUILDER DECLARATION Sign with One Brsnch Cirouit � � � ��•7 5.9�8- I hereby affrm that I am ezempl from the Contractor's License Law � for the followirg reason�Srction 7031.5,Business and Protessions �� ��pnal Sgn Branch Cirwits � . . . ... _.._ . ... . . . codel: • • a 7ra 9 8� � Misa Coriduits&�Conductors "�� � � - �- - � � �� � - � ❑ I,as awner oi the pmperty,witl da tho wark and tha structure Other(See Com�ete Fee Scheduie 0 a G 6�-8? � is not intended or oftered for sale(Section 7044,Business p )— , _ and Protessions CodeJ. � ��-� -�� � � - � �"�"- � � CONSTRUCTION LENDING AGENCY � �� - - - - ��� � -����� - -� I hereby atfirm ihat there is a construc[ion lerdirg agency for[he �r_ � pertormance of the work for which this permR is issued(Sec.3097, pERM1T FEE� ' ' � � �(Suh-Totap-- v -��� ---- --� � � �- - Civ.C.). PLAN CHECKING FEE -�� --- -� � � � � ��� � - � - � - . . . . . - Lender's Name PERMIT ISSUING FEE - . . .. . _ . .�� . . _ ._ � � . ._ . .. _ ._. ... Lender's Address ���� I certify that I have reaa thi5 application and stafe that the above TOTAL FEE_ . , _ ' . .. .. _ . . .. .. ...__ _.. inlormation is correct.I agree to compiy with all County ord'mances arnf State laws regulating Eledrical wiring,and hereby au[ho�ize . _ ... .__ _._ representatives o1 this County to enter upon the a6ove-mentionetl - � � - � - � - - - ��� ��� - - ' - � � pmpe for inspection purposes. - � SEE REVERSE FOR E%PLANATORY LANGUAGE��- - - . - -_ _, _ .. ._ ... . . � �,�e �-�� Si ature of Permittee te � � - f:',^...:ii,�`�... �:.'�,'. #-�..--.. , , . '._"'� 1; ; - --f_ , �_ _._i----_; _.�-,r�--_.._i;t ' , i� - ; ' , j , � �,- ; � I� �.- ' � � � r _i i �� ' � 1 ; '. ! �' � - ` i , , � � � � � � , r ; �-I � � � - I '1 � '`. f - - ` �; = � � ._ � I . � �:�1'' i _ ' �` i ; i- � . . _ I , i� � � .. � — i � i � _ �� ; ' , - '_ I i , - , , . ! _ � t :, ,_ - _ . , ,� . 'z i, v -+r` S 1 �'' c i } i - - � � i -v. � O �'� � �, p z > . , ' t I � _ y r�- -r-i m c z. 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