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,�°R"FRs�`�°","�"5"T`°N°E�L"R"T,°" '6A663 APPLICATION FOR ELECTRICAL PERMIT {�
� � CE-SO6G(2�80)
1 hereby f�ffirm that I have .� crrt�f�cat� oe consent to self COUI�TY OF LOS ANGELES BUILDING ANO SAFETY �J
ineure,ur a oertificate uF Wurkers`Compensation Insurance,ur �
� a cer[ifled copy tharouf(Sec.9800,I,ab.C.) �
j FOR APPLICANT TO FILL IN �pg � � /,y' f ,
�� P�IicY No. (,�inpan}� EACH NO. FEE ADDRESS ,�� ;.��!:��� -�/ �'�.F�
� New Residential Bldgs.&Pools �
� Certificd copy is hereby furnished. 7&2-Family,5q.Ft. g — g LOCALITV �'_ 7 f�,
� Certified co Multi-family Sq.Ft. NEAREST 3
py is filed with the c�iunty building inspection CROSS ST �/,!f��6,� '{�J ��� §��[,�(,s "/yi�+,? '
depar[ment. Residential Swimmin�Pools�"`� �t"�
e( OWNER OR
. �l,l"l'� ��-� G%� FIRM NAME _�____
llate Applicant_ — Outlets:Rec.,_Li9ht_Sw. MAIL � 7 � � //J�.�
First 20 AD� SS � r�C-� �v.� .IG C'
C1SR'f11�ICATE OF EXr:MPl'ION FROM WORKERS' Total No. Additional CITY �' � T¢I No,.�r ,y/ C�' �
COMPENSA'I�ION IRSUKANCL; PLAN CH� � g, � [L
(This section need not be completed if the work InvO1VeQ '. .4PPLICAN ='-- '�,_,�,.����- � ,
Lighting Fixtures First 20 � - o.:« ^
by the permif is for onc hundred dollars (5100)or(essJ , ADORES ���� � .� (Y
Adrlitional
Total No.�_ ' � f
I ccrtify fhat in the perTunnance o(the work for which thix CITV fzi���r;� �'Tel No'" .�C'r�., "� Q
permit is issued,I shall no[employ u}�v pe�5on in any manner Fixed Appliences Not OVer 1 HP ,_„Z IF
so as fo becume subject to the W;ojA:ers' -��mpensution La�vs. Ran e_Heater_�.W._ PEF IT / ��� �+�� j �
. . 9 APPLICAf�kZ_�,��'Y"/��ji�ft,..��.___ Q
Oven _Dryer_W.M._
. y '.7 ,'/�' ADDRESS '�"'��,/ �'� .f. .Ly
._.............. — I
1 7o FAU _W.H._ �"�`�
llate �~�++tCppli�an __��"_"=�"' P CITV f �/� � ..-- '7 I No.r" .�
� - Hood__Fan _Other—_— ;�"✓�����.ff e ...��j��
NOTSCF TO APPLICANI':If,after mssking this Certificate of : Disp. _Room Air Cond._ uCE SE OR 7
F.zemntiun, you should beconte suhjcct to the �Vurkers' REG.NUMBER.:.=3 , '�'F��Clas
�Compcnsxtion provisions nf the Lvbor Code,you must forth- Power Apparatus&Large.Appliances DISTRICT NO. PROCESSE�BY
with comply with such prnvisions or fhis permit shall be � Size_&Type HP,KW,KVA,or KVAR --
demned revoked i
�� UPtotlncl. FINAL � �� .�: [�t{.v�t...
} ! _ Over 1 to 10�ncl. DATE
L[CF:rrSFn con�rtcncToxs��c�wRn'f�o�. rf_.G-��J� VALIDATION
� O�er 10 to 50 Incl. __,
kk I hereby affirm[hnt 1 nm licensed under provisinns of Chupter Over W to 900 Inc. FINAL
� 9 (cummencing u•i[h Section 7000)of'Division J of thtl'Rusi- . OVer 100 BY �
ness and Yrnfecsinns Code,and my license is in full force and �� �Cf-�
effect. �� `�f, `„��' 7 Services
License Numbcf 6 .����yy 0 200 Amp.Under 60D V _
�" 201-9000 Amp.Under 600 V
Cnnhucr�c: � � ����',��ate � '�r �� Over 700U Amp.or Over 600 V
IlOh1@:U14NER-BO[LD};�t pF'CI.AftA'IION Temo.Power Pole&Appurtenances ._ _
.Sign with One Branch Circuit I I
1 hereliy affirm [hat i am ezempl from tLe Contractor'x qdditional Sign 8ranch Circuit5
License Lnw fur the follotviug reason (Section 7031.5, Busi- =�I 6�,"�{i
ness and Prnfessions Coda): -
Misc.Conduits&Conducrors �� o � � m�
� [, as o�vner of the property,will do the work nnd the Other 1See Complete Fee Schedule)— '
structurt is r+ot intended or offered f��r xale (Section .f a q j�,5� .
7044,Husiness and Professions Codc). ��—�---- --�-
CONS'IRUCI70N LI�.Nf]1NG AUGNCY -- -' — °2�,5 0 i�
I hereby affirm that there is a conshuc[ion leitding agency � °
for [he performance of the work for �vliich [his permit is PERMIT FEE (Sub-Total) ��L 3"�C
issucd(Snc.3097,Civ.C). i�.d' (%t,? -
Lendcr's Name — PLAN CHECKING FEE (One-Fourth Permit Fee)
Lender's Address PERMIT ISSUING FEE
} _�
I ceMiFy that 1 have rexd this upplicution and atate that[he TOTAL FEE �f'_��
above infor ation is covect.1 agree to cnmply wilh all County
ordinance� and S�te luws regulating };lectrical wiring, und
hereby a horize presentatives of this County to en[er�pon
�th hu -inen' ned pruper[y for inspection purposes. SEE�R�Vi:KSIt I�i)R EXPLANATOftY LANGl1AGL
' �. �;������--
ignat re u.Permittec Date �
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