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WORKERS'COMPENSATION DECLARATION 76A663 �Oiel APPLICATION FOR ELECTRICAL PERMIT � �
I here6y off�rm�ho�I have a certificote of consent to self �"�
insure,or a cer�i(icate of Workers'Campensation Insurance, I . COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified copy Ihercof(Se[.38D0,lob.C.)
P❑olicy No. Company FOR APPLIGM TO Flll IH JOB _ / C�- q,�
Cerlified copy is herehy furnished. New Residential Bldgs.8 Pools EACH NO. FEE ��RE55 b��' � •.S/�L��� VFt /�(a ,
� Certified copy is iiled wilh Ihe county building inspeo- �8 2-Family,Sq.Ft. s — S ' � IOCALITY D��.{!.0 4sd �if',L�
tion dnparfinent. Mulii-fomily Sq.Ft. — NFAREST r� ,
Residentiol Swimming Pools CROSSSi. /ky�'v� '��� �L J
Dote Appliconl OWNER OR /�
FIRM NAME �Afiie,.� 3�8-�b��r�T' �74
CERTIFICATE OF E%EMPTION FROM WORKERS' Mqil
Oullets:Rec_Lighl_Sw._
COMPENSATION INSURANCE ADDRESS ZZ[x�o C•S!.✓SE�P.PysS/�!L .
Thl��acHon nead naf ba eom let�d if fh�work inmlwd b First 20
( � Y Total No. Addi�ional CITY ��0,y� ���Tel.No.
th�p�rmh is for on�h�ndr�d dollon(5100)or Ins.) PIAN CHECK
I certify thot in tfie performance oF the work for which ihis qVPLIUM
permit is issued,I sholl not employ ony rson in ony monner
so as to be ome sobjeU lo ihe Work Compenw�ion Laws. ligMing Fiztures first 20 ADDRESS
Q Total No. Addi�ional
Dale � v Applim c.{.g�b CITY iel.No.
NOTICE TO APPLIC NT: If, ofter � this Certifimre of FiKed Appliances Nat Over 1 HP . PERMii /� ��y--
Ezemplion, yov should become subject to the Workers' Range_Heater_D.W._ aPP��CP'NT Gtl�'S ��'s ��a..�`�
Compensoifon provis�ons of the lobor Code,you must forth• Oven _Dryer _W.M._ ADDRE55 PQ ��( ��,�
with comply with wch provisions or this permit sholl be Top _FAU _W.H.—
deemed revoked. Hood _Fan _Other_ CITY(��(/yf'� 7e1.No.�`�S–8-�J ,
LICENSED CONTRACTORS DECIARATION LICENSE OR �/ G
I hereby offirm thol l om licensed under provisions of Chopter 9 Disp. —Room Air Cond. — ftEG.NUMBER SI�7�?O 3 Closs.�/G�
(commencing wilh$ection 700p)of Di�ls�on 3 of the Business � Powar Apparatus 8 Large Appliances DISTRICT NO. PROCESSEq.gY �
and Proiessions Code,and my license is in Full force and effect. �O �_\\M Q O
�/ /� /� � /� Size 8 Type HP,KW,KVA,or KVAR «1L"""`
Lfcense Nomber'7'�l �� Lic Closs� FINAL V
p Up l0 1 Ind.
Conrrocro� Date � �C/O Ove�1 to fOlnd. DATE � �S VALIDATION �
❑ Over 10 to 50 Incl. U
FINAI
I om eMempt under Sec Over 50�0 100 int. BY u+
B.BP.C.for this reason Over 100 y
. Services,Swbd.,MCC 8 Panelboards ► z
Doie: 0-2IX1 Amp.Under 600 V '
Signalure i 201-1000 Amp.Under 600 V ,
Over 1000 Amp,or Over 600 V �
� Ezemption tor Reg.Moint.EIecL �
SINGIE FAMILY Temp.Power Pole 8 Appurfenances , � =� � �.G��
HOME OWNER�BUItDER DECLARATION Sign with One Bronch Circuit
I hereby afiirm�hot I am e.empt from ihe ConhaUor's License q�;iional Sign Bronch Circuits ��� � � � ��
Low tor the�ol�awing reosan�Secfion 7031.5, Business and
Professions Code): �,� "G.r7.J G
❑ I,as owner oi Ihe propeny,will do ihe work and ihe Misc.Conduits 8 Condodors e � ";5 C
� slruclure is nol iMended o/of(ered ior salr, (Sec�ion Oiher($ee Complete Fee$chedule)_ , �'` �' .
7044,Business and Professions Code). � �,C�"£�l �
CONSTRUCTION LENDING AGENCY ' �
I hereby affirm Ihat there is a conslruclion lending agency ior /,i r �
Ihe performance of Ihe work for which Ihis permil is issued pERMIT FEE (Sub-Tolol) -�-' - '�
(Sec.3097,Civ.C.�. �
' ' PLAN CHECKING FEE .i� `(�� .
Lender's Name i;' �
PERMIT ISSUING FEE
Lender's Address ����!���
I certify ihat 1 hova reod Ihis applimlion and stole thot ihe TOTAL FEE ti , . '
obove information is mrrect.I agree io comply with all Counry � '
ordinances ond$lote lows regulating Elecirical wiring,and .
heraby au�horize represema�ives of�his County�o enler upon
the obo mentianed pro Ior inspecrion pvrposes. �
_/�9�85� SEE REVERSE FOR EXPIANATORY LANGUAGE . -
I
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