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1714A
� WORKCRS'COMPENSAl10N DECLARATION 76A66� 10/01 �PpLICATION FOR ELECTRICAL PER�MIT � {� ,I I hereby affirm fhat I have a ccrlificate of consent to self insure, ��a�6� �� . 1 or a certificate of Workers Compensation Insurance,or a certified COUNTV OF LOS ANGELES BUILDING AND SAFETY � copy lheroof(uec.3800.Lob.Q) � � � PolicY No. GumpElny FOR APPLICANT TO FILL IN JOB � ' _ EACH NO. FEE AoorteSS s� � ❑ Gertitied copy is hereby furnisherl. New Residential Bldgs.8 Pools LOGALITY j � Certified copy is filed wi[h the county buildinp inspection 1&2-Family,Sq.Ft. � = S � dcoartmr.nt Multi-family Sq.Ft. N[AREST � GROSS ST. � Dalc AppliCant Residcntial Swimminy Pools OWNEIi OR �J'' FIRM NAME t/, E . GERTIRGATE OF EXEMPTION FROM WORKERS' Outlets:R�c�Light—Sw.— NL GOMPENSATION INSURANGE ni�i.»ess /`J . � .�This section�neetl not be completetl if tbe work inqolvetl by the First 7_0 � ~ � permit is for one.hundred doilars($100)or less.) Total No._� Additional CITY ��irZ1�,Q ��Tel.No. `� f'LAN CH[CK j '..I Certify that in the pE�f�OfminCe ot the wofk fol'whiCh fhis p@fnlit ' APPLiCANT �_ � is issued,I shall not emnloy any person in any mannerc so as to � bEcome su6ject to fhe Workcrs'Compensati� Laws. Lighting Fix[ures First 20 ADORESS � � Total No. Additional CITY� �,,,..-� Tel.No.-�""-' Date Applicant ^ Fixed Appliances Nol Over 1 HP pEaMir � �NOTICE TO APPLICANT: If, r ma' �hi Certificate of — . .Exemp[ion,you should 6ocomc subje to t •Workc'Compensation Ranqe_ Heater_ D.W. APPUCANT provisions ut ihc Labvr Codc,you must fo with c mply with such Oven_ �rycr_ W.M._ ADDRESS 3� ,pj�� �l�/�"�'/�, � provisions or tnis permit sh?II 6e dPemetl revolte.r� Top — FAU _ W.H._ GTY " � .� Te 3�� � LICENSED WNIRACTOGtSDEGLARATION Hoocl_ Fan _ Other_ � � I hereby affirm that I.am licensod under provisions of Chapter 0 Disp. — Room Air Cond. — uCENSE�t� -y aass � (Commonciny wifh Seclion 7000)oi Division 3 of tho Business and HEG-NUMeEN �� �l{� a Professions Cotle,anU my license is in full foro2 and effect . �ower Apparalus&Larye Appliances i7is�Ric�No. PhOCeSS�U HV � � �- ,� � Size&Type HP,KW,KVA,or KVAR '�3 '7 � licPnse Num6er ���-^i�7� �ic.Clttss� � Up to 1 IncL FlNAL (� �� �/q�p���� Over 1 io 10lncl. �ATE � y_�/�,�� VALIDATION Canlractor /�//71'/�C.l[�X Date_�-ua__C.Z � � — � Over 10 to 501nc1. FINAL �". � ❑ I am exempt under Sea Over 50 to 100 Inc. gy W_ � � o�E��,00 a � B.&P.C.for this reason . � __ Services,Swbd.,MCG��&P�nelboartls � Z Datc: 0-200 Amp.Under�00 V g Signature_— 207-1000 Amp.Under fi00 V � ❑ Over 1UU0 Amp.or Over 60U V _ Exemp�ion(or Hoy.MainC Etec�. �_ ? � i.�-�A ' SINGLE FAMILY � Tcmp.Po•.va�Polc&P.ppurtenances � �,;n g c w �j � � HOME OWNER-6UILDER�ECLARATION Sign with One Branch Circuit . I hereby aftirm th3Y I 3m exempt from the Contractor's license Law 1 � r '� f �� f����Na h.il..�,d�,o�P____�,rCo�+���,7n_i� R�.��h,oG�a��pm{oG��„„� Additional Sign Branch Circuits . . ' ��� Code): � � � 'i i.2 5� Misr..Conduits 8 Conductors � ❑ I,as owncr o(thc uroDcriy,will do the work and thc structurc �� � iS_�r is no�Intentled or offered tor'sale(Section 7044,Business Othar(Seo Complate Fee Schedule)_ , �and Protessions Code). ' ' ' GONSTRUGTION LENDING AGENGV � I hereby affirm lhcit lhere is a construction Iending ayency for the performanco of the work for which this pormii is issued(Sec.3097, PERMIT FGE (Sub=iotap � � � Civ,C.j. PLAN CHECKING FEE Lende�s Name—�'�1SZ� PERMIT ISSUING FEE �(f Lender's Address �� � � I certify thnt I huvr;re.ad this npplir.rition and s}rite that lhr,abovc TOTAL FEE � infarmation is corrzct 1 agree to comply with all County ordinances �a und St�ate laws regulatinc� Electricaf wiring, and horaby authorize � � representalives of lhis Gounty to entcr upon thc ebovc-mentioneA � � property for iit ectlon purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE r--- , �--- �r-�l9�� � Sign t ie f Peri iltce . 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