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WORKERS'COMPENSATIONDECLARATION 78A663 +o�e� qppLICATION FOR ELECTRICAL PERMIT � � I hereby atfirm that I have a certilicate of consent to seif insure, C6sosc or a certi(icate ol Workers'Compensation Insurance,or a certitied COUNTY OF LOS ANGELES BUILDING AND SAFETY copy thereof�Sec.38DO,Lab.C.) . - PolicyNo.c`�"9o18363Comparry�N�US`��Qt ,ND � FORAPPLICAN7TOFlLLIN:- ",- -� ADDRE55 ��jg SUIJ��y �}}�\EI�ry � � Certified copy is hereby�turnished. . ., New Residential Bldgs.& ol EACH N0. - -. FEE / '•�� Certified copy is fited'with t �counry building inspection 1 8 2-Family,Sq.Ft. � �� � D — S 0 LOCALITY .y2��6-v LOr� 3 6 deparhnent, ��� . . �� � Multi-family Sq.Ft. — NEnRESi. . . r � � CRO55 ST. Residentiaf Swimming Pools Date s � �Applicant r OwNER OR �Q/� � � FIRM NAME�f�4�� E � CERTIFICATE OF EXEMPTION FROM WORKERS' � � ''' �;' � MAiL � � , COMPENSATION INSURANCE � � Oui�ets:Ree—L'gM—Sw:— _ !•�`� - , qpDREss� S I t. 1 t� (Thts set[lon need not be completed if the wotk involvad by lhe First 20 .permil is for one hundred dollars($100)or less.) Total No. Additional� � - CIT � �� Tel.No.����CO I certity that in the performarice of the vrork for whiCh this permR . , _ � `, ��'1 PwN c��ECK • is issued,I shall not emptoy arry person.(n any manner so as to � �" - ����M become subject to the Nlorkers'Compensation Laws. . . L'ghtifg Fiztures Frst 20 � -- - � ADDRE55 - .. . - � � Additional '� -� � Total No. CITY - - �� Tel.No. Date AppliCant - � Fxed Appliances Not Over 1 HP .NOTICE TO-APPLICANT: If, aRer making this Certificate o1 pEppucANT �� � �C �„C��LL .Ezemption,you should 6ecome subject to the Workers Compensatbn Range_ Heater D.W. _ .provisions ol the l.�bor Code,you must forthwith comply with such Oven— Dryer_W.M._ � ADDRESS �,�- �j GX ��lt �provisions or this permit shali be deemed rewked. , Top ,__ FAU__,W.H.__ - �m.0 NO , "'�Tel.No.S�I` YG .LICENSED CONTRACTORS DECIARATION.. Hood_ Fan _Other_ I hereby aflirm that I am licensed under provisions�o(Chapter 9 uCENSE OR p. DiSp. — ROOttI Aif COnd. — pEG.NUMBEft' � �0 p 3 ��40�C (commencing with'Secfion 7000)of Oivision 3 of the Business and � _ 0 Professions Code,and my�license is in full torce and etfect. oisiRicr No. vaocesseo sr Power Apparatus 8 Large Applianr,es �/`(� !���u 3 Lic.Class� � Size 8 Type HP,KW,KVA,or KVAR 1 O ,'\w\o e1�' � License Number �-� ' "Up to i�lncl.' '` -- � -- � - - FINAL- - - �- � EJEcrRcCAL la/¢q o��110 t0incl. �A� _ VALIDA710N a -Contractor� �Oate'___��__,,yf_ �p�r 10 to 50 Incl. FINAL � ❑ I am exempt unaer Sec. Over 50 to 100 Inc. _ gy W B.&P.C.for this reason � Over 100 N � Services.Swbd.,MCC 8 Panelboards- -- � - . . - . . - - - -- . . Z - Date: 0-200 Amp.UnCer fi00 V 7 I � b.�H � Signature ��201-1000 Amp.Under 600 V-�� - � � � �� -� - -� - � - _ -. ��� - - -� - � - - �� �- � Over 1000 Amp.or Over 600 V ❑ Exemption for Reg.6laint Elect. . _ _ #• • • e •2 - - � - - � �SINGLE FAM!LY - �-- Temp.Povrer Pole&Appurtenances � � � � Z� 8 HOME OWNER-Bl11lDER DECLARATION � - '� ' � ��-�"" �--� - - - � I hereby alfirm that 1 am exempt from the Contractor's License Law Sign with One Bmnch Circuit • e � � 2� a� for the following reason(Section 7031.5,Business and Professions -- ��ional Syn Branch Cirwits_ . _ codel: 0&2 6—t3'fl � ❑ I,as owner of the property,wili do the work and the structure Misa Conduils&Conductors� ��-� � - ---�- � - - � -- - , � is not interided or offered for sale(Section 7044,Business Other(See Complete Fee Schedule)_ � and Professtons Cotle). � - �� - � " �- -� ►� �� �� �� � CGNSTRUCTION LENDING AGENCY - � � - ... _ _ . .. .. . . . . _ I he2by affirm that thero is a constnxtion lendirg agency for the , perlormance ot Ihe work for which ihis permit is issued(SeC.3097, pERM1T FEE� ---- - - (Sub•Tofal) � - -. . - . .. . .' Civ.C.�. .._ PLAN CNECKING FEE _ . . _ __. .. Lender's Name � �^ .. PERMR ISSUING PEE . . . . O OO _ . ' . .----. .. . . . . Lender's Address � I ce�tify that I h8t2 t2a0[hiS eppliC2tion antl 51atB th8t ihB 2bove TOTAL FEE � l�� 1 � . . ._. .. . ... _ ... .... __ .. information is correct.I agree to comply with all County ordinances � and State laws regulating Electrical wirfrg,aM hereby authorize representatives of this Counry to enter upon the above-mentioned �� - � - - � ' " � � - --- �- ' -�-- - -- - pro rty for inspection pwp se. . SEE REVERSE FOR EXPLANATORY LANGUAGE ._. .. ._ - - ...-- .... .._ . __ . C A U S nature of Perm�nee D�e , ' � . ,_,. "�1�..� ,'�: .. �r � I _� �f�— ,I--i—I i i`-, ^ , I-- ! , ' � ;-_ , _ ' I � - ' I� � � . � ' j �' e I- � I I I ` � � i �� � � � � � ' I � �+ , �I � I � �y ',- � � ! I � I � ,_ � _ I i I ; _ �`� � i � i Ij�, _ I �� � !` � � � ' i � +`! i - � i i i .. - I I �� � ,�C I ' . L ___ _ _�r I ! 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