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Home My Public Portal About9400 BROADWAY_Electrical__ WORKERS'COMPENSATION DECLARATION '36A663 DPW ais> APPLICATION ��p��®fin ®� ELECTRICAL ��L��Y��p A A ��ppl� 0 'I hereby-offirm that I have a certificate of consent to self 16Ae63 A L A N (� E CAL MH! CE-8066 insure, ora certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS or a,certifyed copy thereof (Sec. 3800, lab. C.) Policy No. Company FOR APPLICANT TO FILL IN JOB .❑Certified copy is hereby furnished. New Residential Bldgs. 8 Pools EACH NO. FEE ADDRESS G G kK /� ❑Certified copy is filed with the county building inspec- 18 2-Family, Sq. Ft. 5 = S LOCALITY tion department. Multi-family Sq. Ft. NEAREST CROSS ST. Q Date - Applicant Residential Swimming Pools OWNER OR II FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec_-L-�Light_Sw._ MAIL1 COMPENSATION INSURANCE ADDRESS Q (This section need not be completed if the work involved by First 20 CITY Tel. No. the permit is for one hundred dollars ($100)or less.) Total No. Additional -�� 3 I certify that in :he s APPLICANT PLAN C ECK performance of the work for which this - ' permit is issued, shall not employ any person in any manner Lighting Fixtures First 20 ADDRESS so as to be ome bject to the W rs'Compensation Lows. Additional ,Q Qy�j Tocol No. CITY Tel. No. V Date D �`x V sl applicant �� v Fixed Appliances Not Over 1 HP PERMIT NOTICE O A LICANT: If, after making this dertificate of APPLICATION Exemption, you should become subject to the Workers' Range— Heoter_D.W. Compensation provisions of the Labor Code, you must forth- Oven — Dryer —W.M._ ADDRESS o AI with comply with such provisions or this permit shall be Top — FAU —W.H. — deemed revoked. Hood — Fon —Other—. CITY 7 Tel. No �• LICENSED CONTRACTORS DECLARATION Disp. — Room Air Cond. _ LICENSE OR Class. I hereby affirm that I am licensed under provisions of Chapter 9 REG. NUMBER (commencing with Section 7000)of Division 3 of the Business Power Apparatus 8 Large Appliances DISTRICT NO. PROCESSED BY aY and Professions Code,and my license is in full force and effect. Size 8 Type HP, KW, KVA, or KVAR 0 License Number Lic. Class Up to I Incl. FINAL �T�'';;��' Over 1 to 10 Ind. DATE Contractor Date VVVV V VALIDATION F_ `` /O Over 10 to 50 Incl. FINAL V am exempt under Sec. Over 50 to 100 Inc. BY B.BP.C. for this reason Over 100 ;21068A d Services, Swbd., MCC 8 Panelboords #.e • ere • L W Date: z 0- 200 Amp. Under 600 V '( • e'1 11,2 5 Signature 201 - 1000 Amp. Under 600 V0/ ov, e a e'1 1,255 ❑ Over 1000 Amp. or Over 600 V Exemption for Reg. Maint. EIecL .1.0 4—8 8 SINGLE FAMILY Temp. Power Pole 8 Appurtenances HOME OWNER-BUILDER DECLARATION hereby affirm that am exempt from the RATIOClOf s License Sign with One Branch Circuit Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits '- - Professions Code): [ I, as owner of the ro ert Misc. Conduits 8 Conductors p p y,ere do sale work and the Other See Complete Fee Schedule D structure isnot intended or offered for sale(Section 7044, ( P )— - Business and Professions Code). CONSTRUCTION LENDING AGENCY . I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued PERMIT FEE (5ub-Totol) (Sec. 3097, Civ. C.). PLAN CHECKING FEE Lender's Name PERMIT ISSUING FEE - Lender's Address S , I certify that I have read this application and state that the TOTAL FEE IOR above information is correct. t agree to comply with all County ordinances and State laws regulating Electrical wiring, and hereby authorize representatives of this County to enter upon thgJpbove-meni property for inspection urpos SEE REVERSE FOR EXPLANATORY LANGUAGE ®s Signature of Permi tee Dote +'•� V/ORKERS'COMPENSATION DECLARATION CE-66 IO/el ' APPLICATION FOR ELECTRICAL PERMIT I liere6 Yf:i rm 0thal I HOY.e'a certificate of consent to self CE-606G y'� insure, o},0 copy thereof e Workers Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY Sr a certified copy thereof (Sec. 3800, lab. C. , OPolicy No. Company FOR APPLICANT TO FILL IN •JOB Certified co is hereby furnished. Tftk� ADDRESS PY Y New Residential Bldgs. 8 Pools T Certified copy is filed with the county building inspec- 18 2-Family, Sq. Ft. LOCALITY / tion department. Multi-family Sq. Ft. NEAREST CROSS ST. Residential Swimming PoolsOWNER OR Dote Applicant ? FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec�Light J $w.� NJ`IL COMPENSATION INSURANCE 7J. ADDRESSThis section need not be coca leted if the work involved b First 20..( F TTotal No. CITY Tel. No. JA 9_ l' the permit is for one hundred dollars ($100) or less.) Additional I certifythat in the performance of the work for which this PLAN CHECK P APPLICANT permit is issued, I shall not employ any person in any manner p so as to become subject to the Workers"Compensation Laws, Lighting Fixtures First 20 J ADDRESS Total No. Additional CITY Tel. No. Date_ ppliccni ed Appliances Not Over 1 HP PERMIT NOTICETO APPLICANT: If, after eking this Certificat of APPLICANT Exemption, you should become subject to the Workers' Range_ Heoter_D.W. Compensation provisions of the Labor Code, you must forth- Oven _ Dryer — W.M.— ADDRESS with comply with such provisions or this permit shall be Top _ FAU —W.H. — deemed revoked. Hood Fan _Other_ p' CITY Tel. No. _ LICENSED CONTRACTORS DECLARATION LICENSE OR Dis _ Room Air Cond. Class. I hereby affirm that I am licensed under provisions of Chapter 9 REG. NUMBER (commencing with Section 7000) of Division 3 of the Business Power Apparatus 8 Large Appliances DISTRICT NO. P ED BY O. and Professions Code,and my license is in full force and effect. f U o U Size 8 Type HP, KW, KVA, or KVAR' ._/' License Number Lic. Class FINAL 0' Up to 1 Incl. DATE 0 Over 1 to 10 Incl. VALIDATION f= Contractor Date❑ Over 10 to 50 Incl. L�j FIN I am exempt under Sec Over 50 to 100 Inc. B B.BP.C. for this reason Over 100 Z Date: Services, Swbd., MCC 8 Ponelboards 0 - 200 Amp. Under 600 V Signature 201 - 1000 Amp. Under 600 V ❑ Over 1000 Amp. or Over 600 V Exemption for Reg. Moint, Elect. SINGLE FAMILY Temp. Power Pole 8 Appurtenances HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit I hereby affirm that I am exempt from the Contractor's License Additional Sign Branch Circuits Law for the following reason (Section 7031.5, Business and Professions Code): N�,( Misc. Conduits 8 Conductors I, as owner of the property, will do the work and the structure is not intended or offered for sale (Section Other (See.Complete Fee Schedule)_ :1537.4A 7044, Business and Professions Code). D #'-i- is 0,0 2 CONSTRUCTION LENDING AGENCY 1'-.- 2625 I hereby affirm that there is o construction lending agency for the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) s s s 2 b 2 5 5 (Sec. 3097, Civ. C.). PLAN CHECKING FEE 0'Q 9 5'_'8 6 Lender's Name D PERMIT ISSUING FEE ' Lender's Address I certify that I have read this application and slate that the TOTAL FEE �r above information is correct. I agree to comply with all County - ordinances and Stole laws regulating Electrical wiring, and hereby authorize representatives of this County to enter upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ' S�.nature of Perm Jle Date WJORKER$_ COMPENSATION DECLARATION CE-663 10/61 APPLICATION FOR ELECTRICAL PERMIT {� • •1 hereby !J irro that I have a certificate of consent to self-insure,. CE-806G LJ br a certificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY copy thereof.(Sec.3800,Lab.C.) • Policy No. Company _ FOR APPLICANT TO FILL IN JOB _❑ Certified copy is hereby furnishetl. New Residential Bldgs.8 Pools EACH NO. 'FEE ADDRESS _ ❑ Certified copy is filed with the county' building inspection 1 8 2-Family,Sq.Ft. $ — $ LOCALITY department. MUlti-family Sq.FL — NEAREST ' CROSS ST. Residential Swimming Pools Date Applicant - OWNER OR 4. FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Ree Light _ Sw� MAIL _ COMPENSATION INSURANCE ADDRESS (This section need not be completed if the work involved by the First 20 , Total No. Additio CITY Tel.No. permit is for one hundred dollars ($100) or less) - I certify that in the performance of the work for which this permit G PLAN CHECK is issued, I hall not em 10 an APPLICANT p y y person in any manner so as to /� . - become su ecf to he Workers Compen tion Laws. L'ghtina Fixture First ADDRESS �.• n Additional //' Total No. CITY Tel.No. Data LI Applicant fixed Appliances Not Over 1 HP • NOTICE'110 APPLICANT: If, after a ing this C rtific of PERMIT .Exemption,you shoultl become subject the.Wolkers'Compensation Range__ Heater_ D.W. APPLICANT 14,11 previsions of the Labor Code, you must forthwith comply with such Oven Dryer _ W.M._ ADDRESS provisions or this permit shall be deemed revoked. i . Top FAU ,_ W.H. _ - LICENSED CONTRACTORS DECLARATION CITY - - 'Tel.No' 1 herebyaffirm that I am licensed'under Hootl — Fan Other_ pr3V ofOthe of Chapter 9 Disp. Room Air Cone. LICENSE OR -. (commencing with Section 7000) of Division 3 of theBusiness and REG,NUMBER Gass, Professions Code,and my license is in full force and effect. WDISTRICT NO. i/ PROCESS V Power Apparatus& Large Appliances ��] • �1U/r ., Size&Type HP, K ,KVA,or KVAR �./L License Number Lic.Class Up to 1 Incl. FINAL n U Over 1 to 10 incl. DAT IDATION Contractor Date Over 10 to 50 Incl. ( CCCJJJ U ❑ I'am exempt under Sec. Over 50 to 100 line. EI U W 8.8 Over 100 P.C. for this reason d Services,Swbd.,MCC& Panelboards Date: Z 0- 200 Amp.Under 600 V r-'+ Signature 201 - 1000 Amp.Under 600 V ❑ - Over 1000 Amp.or Over 600 V Exemption for Reg.Maint. Elect. 279, Q 2 A SINGLE FAMILY Temp.Power Pole& Appurtenances #'e e 0 o a'2 HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit I hereby affirm that I am exempt from the Contractor's License law eo 25.5 for the following reason(Section 7031.5,Business and Professions Additional Sign Branch Circuits 01 Code): 2 5l 5.0 5 Misc.Conduits& Conductors ... I,as owner of the property,will do the work and the structure Other (See Complete Fee Schedule) '•o9.2 3 +8 7 is not intended C offered for sale (Section 7044, Business D and Professions Code). -' - • - - CONSTRUCTION LENDING AGENCY - - I,hereby affirm that there is a construction lending.agency for the - - performance of the work for which this permit is issued(Sec.3097, PERMIT FEE - (Sub-Total) Civ. CJ. _ .. PLAN CHECKING FEE - Lender's Name ' PERMIT ISSUING FEE Lender's Address r - I certify that I have read this application and state that the above TOTAL FEE SiJ information is correct.I agree to comply with all County ordinances - - - and State laws regulating Electrical wiring, and hereby authorize r _ representatives of this County to enter upon the T -m tioned - - - party for inspection purposes. SEE.REVERSE,FOR EXPLANATORY LANGUAGE i nature of Per ittee WORKERS'iCE-806G APPLICATION FOR ELECTRICAL PERMIT 'COMPENSATION DECLARATION -663 10/e1 �. . OE I hereby affirmm that have a certificate of consent to self insure, ' or a certificate of Workers' ComQensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY copy thereof(Sec.3800,Lab.C.) - Policy No. - - Company FOR APPLICANT TO FILL IN -. .JOB copy y- New Residential Bldgs.& Pools- ADDRESS ❑ Certified co is hereby-fur furnished. EACH NO. FEE LOCALITY ❑ Certified copy is filed with the county buildirig inspection 1 & 2-Family,Sq.Ft. S — $ debartment.,• Multi-family Sq.Ft. — NEAREST / L L CROSS ST. L da+' DateApplicantResidential Swimming Pools -OWNER OR ' s - p FIRM NAME (�/•� •CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Reca.L Light Sw. AIL Y COMPENSATION INSURANCE _ ADDRESS (This section need not be completed If the work involved by the First 20. �! r/ permit is for one at dollars ($100)'or less.) Total No.J- Additional CITYin GG UIVIel.No. i d l I certify that in the performance-of'the woik for which this permit PLAN CHECK is issued 1 shall not employ any.person in any manner so as to APPLICANT become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS - �Q Additional Total No Date d/..3 A Applicant . CITY Tel.Na NOTICE TO APPLICANT: If, after; akin this Certific to of Fixed Appliances Not Over 1 HP PERMIT - Exemption,you should become subject4o,the Workers'Compensation Range_ Heater_ D.W. APPLICANT provisions of the Labor Code, you must forthwit4 comply with such 'Oben _ Dryer _ W.M._ ADDRESS provisions or this permit shall be deemed revoked, 'Top — FAU _ W.H. _ _ LICENSED CONTRACTORS DECLARATION Hood Fan CITY Tel.No.Other_, ' I hereby affirm that I am licensed under'provisions of Chapter 9 - LICENSE OR (commencing with Section 7000)of'Division 3 of the Business and Disp. — Roam Air Gond. REG:NUMBER. - Class. Professions Code,and my license is in full force and effect. DISTRICT O. PR 55ED By Power Apparatus& Large Appliances Size& Type HP,KW,KVA,or KVARl 0 License Number Lic.ClassUp to 1 Incl. FINAL'. U f. .._ - , Over 1 to 10 Incl. DATE VALIDATION 0: Contractor - - Date - Over 10 to601nc1. - ❑ U am exempt under Sec. Over 60 to 100 Inc. FINAL By LLI BARC. for this reason - Over,100 - 1 - N Services,Swbd.,MCC& Parlelboards. D Luf Z Date: 0-200 Amp.Under 600 V Signature 201 - 1000 Amp. Under 600.V ❑ - - Over 1000 Amp.or Over 600 V - - Exemption for Reg.Maint.Elect. ..1 SINGLE FAMILY Temp.Power Pole& Appurtenances HOME OWNER-BUILDER DECLARATION - - ACCT.: Sign with One Branch Circuit I hereby,affirm that I am exempt from the Contractor's License Law �•�� for the following reason(Section 7031.5, Business and Professions Additional Sign Branch Circuits - JOV7 2d.,,0 Code): _ J Misc.Conduits& Conductors ITEMS" .1 El1. - "'."-" I,as owner of the property„will do the work and the structure 2 is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) TOTAL 23.150 and Professions Code). �.- CASH 23.50 CONSTRUCTION LENDING AGENCV ,- - �A' • goo - I hereby affirm that there is a construction lending agency for the � � r-. -^: CHAKG performance of the work for which this permit is issued(Sec.3097, Civ.C,). PERMIT FEE,., (Sub-Total)_ - - - PLAN CHECKING FEE _ QOyU-000 1 L0/30/V4 Lender's Name PERMIT'ISSUING FEE 10. 50 _ 6440 1 AM 8:09 Lender's Address I certify that I have read this application and state that the above TOTAL FEE .23 5G information is correct. I agree to comply with all County ordinances and State laws regulating Electrical wiring, and hereby authorize - - epresentatives of this County to enter upon the above-mentioned - - property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE i �9 J�Sq,gn ". ermittee Dat - WORKERS' COMPENSATION DECLARATION 16.-663 10/61 APPLICATION FOR ELECTRICAL PERMIT {� I hereby aiiirm that I have a certificate of consent 1p-self insure, CE.e06G �J a^a certificate of workers' Compensation Insurance, or a certified- COUNTY OF LOS ANGELES BUILDING AND SAFETY copy thereof (Sec.3800,Lab. C.) Policy No. Company FOR APPLICANT TO FILL IN I JOB---- Certified copy is hereby furnished. New Residential Bldgs.&Pools EACH, I NO. FEE Certified copy is filed with the county building inspection 1 & 2-Family,Sq.Ft. S I—Is I LOCALITY department. Multi-family Sq.Ft. — NEAREST ZV CROSS ST: Date Applicant Residential Swimming Pools OWNER OR Aq � FIRM NAME 1"' CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec� Light _ Sw.— MAIL COMPENSATION INSURANCE ADDRESS (This section need not be completed if the work irivolved by the First 20 permit is for one hundred dollars ($100)or less.) Total No. Additional CITY Tel.No. I certify that in the performance of the work for which this permit PLAN CHECK is issued, I Shall not employ any person in any manner 50 as 10 APPLICANT become subject to the Workers'Co sation Laws. Lighting Fixtures - First 20 ADDRESS Total No. Additional CITY Tel,No. Date Applicant Fixed Appliances Not Over 1 HP PERMIT NOTICE APPLICANT: If, after making this Certificate of APPLICANT Exemption,you should become subject to the Workers'Compensation Range_ Heater_ D.W. provisions of the Labor Code, you must forthwith comply with such Oven _ Dryer _ W.M._ ADDRESS / provisions or this permit shall be deemed revoked. Top _ FAU _ W.H. LICENSED CONTRACTORS DECLARATION CITY Hood — Fan Other_ Tel.No. hereby affirm that I am licensed under provisions of Chapter 9 Dista. — Room Air Cond. LICENSE OR (commencing with Section 7000) of Division 3 of the Business and REG.NUMBER Ns. - Professions Code,and my license is in full force and effect. DISTRICT NO. PR E D eY Power Apparatus 8 Large Appliances d Size& Type HP,KW,KVA, or KVAR /O O License Number Lic.Class Up to 1 Incl. FINAL ( U Over 1 to 10 Incl. DATE 0 Contractor Date V' VALID ION ❑ Over 10 to 50 Incl. I am exempt under Sec. Over 50 to 100 Inc. gy AL W B.&P.C. for this reason Over 100 IL N Services,Swbd.,MCC & Panelboards D Z Date:- 0-200 Amp.Under 600 V r+ Signature 201 - 1000 Amp.Under 600 V ❑ Exemption for Reg.Maint.Elect. Over 1000 Amp.or Over 600 V SINGLE FAMILY Temp.Power Pole& Appurtenances ? HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit At.(.T.i I hereby affirm that I am exempt from the Contractor's License Law for the following reason(Section 703 1.5,Business and Professions Additional Sign Branch Circuits Code): 3_307 15.70 I,as owner of the property,will do the work and the structure Misc.Conduits& Conductors 1 ITEMS Other(See Complete Fee Schedule) _ is not owes C offered for sale (Section 7044, Business D TOTAL i s 70 and Professions Code). CONSTRUCTION LENDING AGENCY CHECK 15.711 1 hereby affirm that there is a construction lending agency for the - CHANGE .00 performance of the work for which this permit is issued(Sec.3097, PERMIT FEE (Sub-Total Civ.C.). Lender's Name PLAN CHECKING FEE 15000'0001 7/ 6/51) Lender's Address PERMIT ISSUING FEE 1689 1 AM 7.1. 1 certify that I have read this application and state that the above TOTAL FEE ITA information is correct. I agree to comply with all County ordinances lij and State laws regulating Electrical wiring, and hereby authorize representatives of this County to enter upon the above-mentioned pr rty for inspection purp sea. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee V Date e/yy �([S'COMPENSATION DECLARATION CE 803 IO/el p�lml�0 ICATION"FOI® ELECTRICAL SO ECTRIC A A PERMIT .I hereby'affirm dt I' have a certificate of consent to self CE806GP11f�Ir IL 'l.i'Y 0 0�1 Yi IG IL IG II 'bP'i IL PERMIT YIGVY 0 %msure, An of Workers' Compensation Insurance,_ � COUNTY OF LOS ANGELES BUILDING AND SAFETY s`or a certified copy thereof (Sec. 3800, Lab. C.) Policy No. - Company FOR APPLICANT TO FILL.IN JOB Certified copy is hereby furnished. New Residential Bldgs. 8 Pools EACH NO. FEE ADDRESS ❑ Certified copy is filed with the county building inspec- 1 8 2-Fomily, Sq. Ft. E — $ LOCALIT tion department. Multi-family Sq. Ft. — 'NEAREST Dote Applicant Residential Swimming Pools CROSS ST. OWNER OR - FIRM NAME CERTIFICATE OFEXEMPTION FROM WORKERS' Outlets: Rec_LightSw._ MAIL COMPENSATION INSURANCE First 20 ADDRESS (This section need not be completed if the work involved by Total No. - ' CITY Tel. No. the permit is for one hundred dollars ($100)or less.) Additional .JVD PLAN CHECK I certify that in the performance of the work for which this APPLICANT permit is issued, I shall not employ any person in any manner so.as to become to the Workers'Compensation ws. Lighting Fixtures First 20 7 ADDRESS Total No. Additional CITY Tel. No. Date Applicant r axed Appliances Not Over 1 HP PERMIT NOTICE O A PLICANT: It, after king this Certificate of APPLICANT Exemption, you should become subject to the Workers' Range'_ Heater—D.W. Compensation provisions of the Labor Code, you must forth- Oven _ Dryer _ W.M.,K ADDRESS with comply with such provisions or this permit shall be Top _ FAU —W.H.tg '�- CITY N Tel. No. deemed revoked. Hood _ Fan _ Other_ LICENSED CONTRACTORS DECLARATION LICENSE OR I hereby affirm that I am licensed under provisions of Chapter 9 Disp. _ Room Air Cond. REG. NUMBER VBY (commencing with Section 7000) of Division 3 of the Business DISTRICT NO. PROCEand Professions Code,and m license is in full force and effect. Power Apparatus 8 Large Appliances /� YyIL Size 8 Type HP, KW, KVA, or KVAR (� O License Number Lic. Class Up to 1 Incl. DATEOver I to IO Incl. •00 Contractor Date Over 10 to 50 Incl. FINAL O ❑ I am exempt under Sec. Over 50 to 100 Inc. BY ••��"" W B.BP.C. for this reason Over 100 ;F7 1 Q Q A N Services, Svrbd., MCC 8 Ponelboards # e e e e e '2 Z Date: 0 -200 Amp. Under 600 V � I ° ° 2 5 5 O Signature 201 - 1000 Amp. Under 600 V Exemption for Reg. Maint. Elect, 1000 Amp. or Over-600 V e.° • 2 a 5 0 6 ❑ - 0526-87 SINGLE FAMILY Tem Power Pole 8 A p. Circuit ances HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit I hereby affirm that I am exempt from the Contractor's License Additional Sign Branch Circuits Low for the following reason (Section 7031.5, Business and Ass Code): I, as owner of the property, will do the work and the Misc. Conduits 8 Conductors '- structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ D 7044, Business and Professions Code). .J CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued PERMIT FEE - - (Sub-Total) - (Sec. 3097, Civ. C.). PLAN CHECKING FEE - - Lender's Nome PERMIT ISSUING FEE - - 0 � L Lender's Address I certify that I have read this application and state that the .TOTAL FEE above information is correct. i agree to comply with all County ordinances and State lows regulating Electrical wiring, and - hereby authorize representatives of this County to enter upon the above-mentioned property for inspection p rposes, SEE REVERSE FOR EXPLANATORY LANGUAGE 0 ignature of Permits Dote , COMPENSATION DECLARATION �M3 DPW 3/67 �,PIPd9CATB®Y V FOR ELECTRICAL PERMIT Y 1 r that have a certificate of consent to self •CE_ Bpya insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS or a certified copy thereof (Sec. 3000, Lab. C.) Policy No. Company FOR APPLICANT TO FILL IN JOB Certified copy is hereby furnished. New Residential Bldgs. 8 Pools EACH NO. FEE ADDRESS Certified co is filed with the count building inspec- 18 2-Famil S Ft. $ = S LOCALITY 1 PY- Y 9 P Y. q� `\ tion depar men Multi-family Sq. Ft. NEAREST Date Applicant Residential Swimming Pools OWNER UK J FIRM NAME L CERT KATE OF EXEMPTION FROM WORKERS' Outlets: Rec `�- Light_1_Sw.1 MAIL t, COMPENSATION INSURANCE First 20 ADDRESS gotol' (This section need not be completed if the work involved by Total No. Additional CITY L+ T.I. No- the permit is for one hundred dollars ($100)or less.). PLAN CHE K �C I certify that in the performance of the work for which this APPLICANT permit is issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensat'an LawS. Lighting Fixtures First 20 ADDRESS B '� Total Na. ;!-- Additional CITY � Tel. No.� Date % Applicant Fined Appliances Not Over I HP PERMIT NOTIC TO PPLICANT: If,.q6,4.king this Certi icate of APPLICATION Exemption, you should bec a subject to the Workers' Range— Heater—D.W. _ Compensation provisions of the Labor Code, you must forth- Oven _ Dryer —W.M._ ADDRESS -4S. N with comply with such provisions or this permit shall be Top ' — FAU —W.H. — deemed revoked. Hood — Fan —Other_ CITY Tel. No. , j LICENSED CONTRACTORS DECLARATION LICENSE OR Disp. — Room Air Cond. _ REG. NUMBER Class. I hereby affirm that I am licensed under provisions of Chapter 9 - (commencing with Section 7000)of Division 3 of the Business Power Apparatus 8 Large Appliances DISTRICT NO OC SED BY and Professions Code, and my license is in full force and effect, g Cl- . Size 8 Type HP, KW, KVA, or KVAR o 0 License Number Lic. Class Up to 1 Incl. FINAL Over Lto 10 Incl. DATE VALIDATION Contractor DateOver 10 to 50 Incl. O FINAL am am exempt under Sec. Over 50 to 100 Inc. BY W B.SP.C. for this reason Over 100 d Services, Swbd., MCC 8 Ponelboards Z Date: z 0- 200 Amp. Under 600 V Signature 201 - 1000 Amp.-Under 600 V Over 1000 Amp, or Over 600 V Exemption for Reg. Maint. Elect. SINGLE FAMILY Temp. Power Pole 8 Appurtenances HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit I hereby affirm that I am exempt from the Contractor s License Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits Professions Code): as owner of the property, will do the work and the Misc. Conduits 8 Conductors / structure is not intended or offered for sale(Section 7044, Other (See Complete Fee Schedule)_ D Business and Professions Code). CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) (Sec. 3097, Civ. C.). PLAN CHECKING FEE L Lender's Name PERMIT ISSUING FEE Lender's Address I certify that I have read this application and state that the TOTAL FEE above information is correct. I agree to comply with all County 9—1/0 ordinances and State laws regulating Electrical wiring, and - r hereby authorize.representatives of this County to enter upon the ab ve-mentioned property for inspection pur ores. SEE REVERSE FOR EXPLANATORY LANGUAGE Signatdre of Permittee _ ate 1 ,