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�� �WORKER§�GOMPENSAnON DECLARATION 7enG63 10/61 � �he«bY,ff;.�n th���na�e a certificatc o��ons��t to S��f��s���. �E�°hG APPLICATION FOR ELECTRICAL PERMIT {� � or a certificate ot Workers Compensation Insurance.or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY �J ppp copy thereoi(Sec.380�,Lab.C.) j PoliCy No_ �ComPany FOR IIPPLICANT TO FILL IN JOB �/_�� `�` j ❑ Cerlifir,d copy is hereby fumished. New Residential BId9s.&Pools EACH NO. FEE AooaEss �y t � Certified copy is filed with the county building inspection �N�2-Famiy,Sq.Ft. R = $ LOGALITV } �.department. Multi-family Sq.R. CF055SS7. ' . �� ��, " � ResidentiaI Swimminr�Pools �Date Applicanf /� � � OWNEROR �' (� � p ' /_Yfi0 �, fIRM NAME 4, („ � 1„Y..3' � Q� � � CERTIFICATE OF EXGMPiION FROM WORKERS' � MAIL Outlets:Rec—Li4ht—Sw.— ! � WMP[NSAlION INSURANCE AUDfiESS S,�r (This section need not be completed if the work involved by the Fiist 20 � .permit is for one hundred tlollars(5100)or less.j, 'folal No. Additional CITY .. TeL No. e� � { PLAN CHFCK'"�'n ' I certify tha}in the perforrnance of Oie work for which this permit .. � APPLICAN f �d�� �y� �CJ� � is issucd,I shal!not employ arry pergon iq nny manncr so as lo � �bcr,ome suhject to Ihc Workers'Gom ensation Laws. � Lighting Fixtures Pirst 20 ADDRESS ' ej� �. � �']] pp Total No. Additional w � Opte���Applicant CITY� Tel.No. � NOTIC� TO APPLICANT: If, after making this Certificale of Fixed Appliances Not Over 1 HP ptqMii � ; � Exemption,you shoultl Uacoma subject to lhe Workeri Compensation Range_HeEtter_ �.W. _ APPLICANT � provisions ot thr.Lahor Cocle;yQu muyt forthwith comply with sur,h Ovan _ Drypr_ W.M_ ADDRESS 7% �-5/� ..i �,_�Cn . proyisions or thi,permit shnll be deemed revoked. Top — FAU _ W.H._ ` CITY• Tel.No. LICENSED CONTRFlCTORS DF_CLARATIdN e, �' � ,�li � �/" �jG"� Hood— Fan Other_ I hcre6y a(firm that I am licensed under prov,isions pf Chapter 9 Disp. — Room Air Cond. _ uCENSE Of7 - - (COmmenCing wiih Section%�00)of�iuision 3 of the BUsinoss and ' fi[G.NUMBER �1"G^ '- Professions Cade,and r.iy license is in full forr.e antl effnef. OISiHICT NO PROCESSED 6Y Power ApparaWs&Larye Appliances �� � j , Size&Typc HP,KW,KVA,or KVAH ; f . ` License Number Lia Gless Up to 1 IneL FlNAL r' � `'L,(r (j . Ovcr 1 to 10 Incl. DATE �� :?��s._....�r��� { � �Con[ractor_ Dafc Over 10 to 50 Incl. FINAL�/. � VALIUATION O ❑ I am exemn[mider Scc. Over 50 l0 100 Inc. gy �� �,���� U 6.&P.C.'ror ihis reason ---Over 100 �_ ; � ��'.(�� a Services,Swbtl.,MCC&Panelboards � � � @ � Dat2: ---- 0-200 Amp.tlnder 600 V �p R��&t. r��'. � {f Siynaturc 201-1000 Amp.Undcr 600 V `�b'���"� � 9 ❑ Over tU00 Amp.or Over 6UU V ���9 � Exemption for Re�.Maint.Elect, � � � SWGLc PAMILY T2mp.Power Pole&Appurtenances �q HOME OWNER-6UILDCR�ECLARATION Sign wilh One Branuh Circuit i� ' I hereby a(firm that I am excmpt from the Contractor's License Law F...<<.,. - _ _ _ _ _ __ Addifiona�Sion Rranr.h Cirr,uitc 1 Q A �A CUtla):`V �y••• f�, � �, I,asvowner of the property,'will do the work,and the structure Misc.Conduits&Conductors 1 `��^-X� Other See Com � � is not intended or offered for sale(Section 7044,Business ( plete Fee Schedule)_ , and Professions Code�. � � CONSTRUCTION LENDING AGENCY I hereby affirm th;�t thcrc is a construction Icndin3 agency for the �perforinance of ihe work for which tYiis perrnit is issued(Sec.3097, pERMIT FEE (Sub-Total) � � Civ.C.). fy�_ PLAN CHECKING FEE . Lendcr's Name �.�' � PERMIT ISSUING FEE Landers Address � r�Q I certify thai I have read this applicaiion and siate thai the a6ove TOThL FEE . �intormaliun is correct I ag�ee to comply with all County ordinances �and St.tc laws regidatiny Flectrical winng. 2nd hcrcby authorize ' representatives ot lhis County tu enter upon the above-mentioncd - pro orty for inspection pu�poses. � SEE REVERSE FOR EXPLANATORY LANGUAGE . � r� t ignat re of Permittee Date � i ^�^ ti, � �iM1, . ' " . ;,,..,' ` ' � :` , �i ,��k `�l `t�? 'J .• . ... . .., •}} �'` t`� �� �[�� `l.:`, �l �� t�•t � '� , . . ' - ; �� ��, � �; ���\ ���� � , '` �`� ' ,+` ..��i �`', � . ` � .'. . 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