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NJORKERS'COMPENSATION DECLARATION 76A683 ior8i J"1 � I hereby affirm that 1 have a�e���,,��e o�consent to sel(insure, CE-806a APPLICATION FOR ELECTRICAL PERMIT u ' or a certiticate ol Workers'Compensation Insu2nce,or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY � copy thereof(nSec.3800/.1ab.C.) � Porcv Nc�aT"I�IFS3pZCOmpgny���nU S���AL `NI�_ FON AVPLICANT TO FILL IN . JOB o� Q -{- .❑ .Certified copy is here furnishetl. - EACH NO. .. _ FEE ADDReSS- o�-JUV�� RNI QQ bl „ . New Residentiai BMgs.d P�}ols�L/� . . . � ..� � . . 1 8 2-Family,SQ.FL�L� S � — 5 LOCALITY � 2 S� -V � $ � CertifieA�'copy is filed'with t county buiidirg inspection _ . department.- � .� - �� � -�,� Mu!ti-family Sq.Ft. NEAREST , ' �'p . . . . ._. . _... CROSS ST.�. . OA Date 30� �� � � ' Residential Swimmirg Pools � �- �� � � � oWNER oR ' Applicant ' F�RM NAk7E A{� I C�- __. ' - ... ... -. � CERTIFlCATE OF EXEMPTION FROM WORKERS' Out�ets:Rec—Light_Sw.— � --- Ma� 4 q . � �. . , COMPENSATION INSURANCE - - -� � -� � ADMESS�J�S - �I W H V C , (This section need not be compleled H the work involved by the � Frst 20 CITV � T I.No. .permit Is for one hundred dollars($7D0)or Iess.) Total No. Additional -�OS A Sa 262 $50-10 0 . PLAN GHECK - �- - I certity that In the performance o(the work for which this�permit - � - - - ppp��qM � - --- -- - becosmedsu6lect'to the Workers C mpensa[ionn�YmKanner so as to L'ghtin Fxtures First 20 � 9 . _.. . _._ .. . AODRESS . .._...' . - � . � � �� - � • .. � Total No. Additional � ��TY . .- - . . Tel.No. , . - Date Applicant � " Fxed Appliances Not Over 7 HP pERMIT `� i� NOTICE�.TO��APPLICANT:�If, afte�-making this Certificate of C��� C ����� Exemption,you should become su6pct to the VJorkers'Compensation Ran9e_ Hea[er_D.W. _ AaPIJCAM I p!evisicn5 oF the LaAor Cnde,you must farihwith comply with such Oven_ Drye�_W.M._ AODRESS �,O � 'I provisions or this permit shall 6e deemed rewked. Top. _ PAU _W.H._ f LIGENSE�CONTRACTORSDECLARATION� ,, Hood_Fan _Other_ � - CITYC p � ��� �� 7eI.No.s f-6f� � 1 I hereby affirm Ihat I.am licensed uMer provisions ot Chapter 9 LJCENSE OR ^i (commencing with Seclion 7000)oF Oivision 3 of the Business and � -�Disp. —Room Air Cond. _-�- ��q QD g-p-���-� C�s.C-�U - REG.NUMBER' i Pfo(ESSiOfIS COdO,flfld rtly IiCEn58 i3 In full fOfCB df1�Bf12Ct. PpWgf Appafdfu5 8 L3rge App�i3nCes D�STRICT NO. PROCESSED BY Size 8 Type HP,KW.KVA or KVAR � � � ._. ..._._ . . _ . LI�PDO$'3 C-Io 1 c� on � � � . ._ . '..UP to 1 Incl..- . .. . . .- -� FINAL .. License Number Lic.Class - -- - ""-� -- -"�--- - ---� � Over 1 to 10 Incl. �A� �y� VALIUATION � ' � Comractor-F�ECrRI�AL Date' `.;'.�t�� . . __ ._ . .- - - . . ._ _ . ._ � �.O�.. .. .._ __. .- � i ; Over 10 to 50 Incl. flNAL � � I ❑ I am exempt under Sec. -_ - ._, Over 50_to 100 Ine. , . V � - -- . .. ._. . '--.. BY__._ _ y,A . � 6.8P.C.for this reason Over 100 �l 0. �� � Services;Swbd.,MCC 8 Panelboards��� . � � � �-- �� ��7�Q A - � � _ _ .. . . - -- --- Date:--- --- � ��-� 0-200 Amp.Under 600 V '"+ Signature `.. ...-201-�1000 Amp.Under 800 V-._.... ._ . ._..__ . ...- ._ .. . .'. .... .. .�*�.� �.�_�2 . -- � - ��- � � � � �� � - - �� �� - "- Over 1000 Amp.a Over 800 V � � � � •9 Q 2 6 ' ❑ Exemption for Reg.Maint Elect � ��- � - � � � -� - - - -- � - � � �- � . � � SMGLE FAMILY - - - � � Temp.Power Pole&Appurtenances ' • • °9���? HOME OWNER-BUiLDER OECLARATION - �� � ������ � � �� � � ��-������ - �- - - �� � - I here6y affirm that I am exempt from the Contrector's�icense law Sign wRh One Branch Cimuit 0 8.2 6—a 8 for the fotlowirg reason(Section 7031.5,Business and Professions Additional Sign Branch Circuits .. _..._ ._ -. . .__. .... .. . ___.__._.. ..--_ __ _..__ . .._ . Code): � - Misc.Canduits&Conductors � -- ---- - - - -- � � � � -� ❑ I,as owner of the pmperty,witl do the wak and ihe sttuCture � is no[intended or ctfered for saie(Section 7044,Business Other(See Compiete Fee Schedule)_ � � � and Pmfessions Codel. - - ... . . _. . ___ . . . . .... . . .. ....�...... .... . CONSTRUCTION LENDING AGENCY � - - � - � - � � �-- - � � - -� � I hereby affirm that there is a constroction lendirg agency for the � pertormance of the vrork for which this permit is Issued(Sec.3097, - pERM1T FEE --� - � --��---�- -ISub-Tota�)- � $s � �-� � � � � - �� - . Civ.Q1. ' ." " .. � . . PLAN CHECKING FEE. �. ._ . ... . .... .: _.. _ . . � . .. . _ .. . . . . . � Lender's Name � . PERMR ISSUING FEE � . I U D . . . . . ._.. - . ._ _ . _ . .. LenCer's Pddress • �! ,26 � I certi(y ihat I have read this applieation and state ihai the a6ove,._ TOTAL FEE _ b . _.._.. .. .. . __._.. _ Intormatbn is correct.I agree to comply with ali County ordinarices and State laws 1egulating ElectriCal w(dng,end hereby aWhorize mpresentatives of this County to enter upon the above•menCroned � - �- � - � - � -� �-��� - - ��� � � - � � ����� � � �� � � ��� � �� �-�-�� pmper y for inspedion purpose _ SEE REVERSE FOR EXPLANATORY.LANGUAGE _ . � � .. _. ___ . . .. _ ..._ . . . _ . . .... . ...... . -- Sig ature of Permittee ' Date - I . ., .�-s._�:'_`:C;. :��..._ , i� �f � �— -T� —, i— ; --- ------,- ---, - --____._. i ;_' �. i ��. I i � 1_ ' _ � _ ,; i I �.� ' � ; ^ �_ S �_ � � � � i = ; ! _ . �; �", i I"� i�� ' � � � � - . -� � :- �! 'I I � � .� � - �_ c•� � i �--I ( ; �v. 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