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WORKER'S that.1have a certificate
DECLARATION 76AB63 DPW 91e9 APPLICATION FOR ELECTRICAL PERMIT Llll
6A863
• I hereby affirm that.1 have a certificate of consent to self insure,
or a cWtificpte.of-Worker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV.
copy thereof(Sec.3800 Lab.C.).. �'"�'
Policy No. DO 57�Z Company✓ �fyM FOR APPLICANT TO FILL IN - j JOB � �J D
❑ ADDRESS '/ b
Certified copy is hereby furnished. h''f��11 New Residential Bogs.&P lyp s�G 3 EACH ' NO. SEE LOCALITY
' 1&2-Family,Sq. I.
d $ — $ c
Certified copy is filed with the county building inspection
department'. NEAREST
-family Sq.Ft.T _ MultiCROSS
�— 9 Z - Residential Swimming Pools ASSESSOR
Dale Applicant MAP BOOK _
PAGE PARCEL
-CERTIFICATE OF EXEMPTION FRO ORKERS' OOWNER OR / '•J /
Outlets Rec. FIRM NAME
-.. f COMPENSATION INSURANCE '
First 20 MAIL(This section need not be completed if the work involved by the - ,
permit is for one hundred dollars($100)or less.) Total No. Additional ADDRESS '
I certify that in the performance of the work for which this permit - CITY -- -.- Ter No. `
is issued, I shall not employ alloy person m any manner'so as to PLAN CHECK,
become subject to the Workers' Compensation Laws. Lighting Fixtures _ First 20 - APPLICANT
Total No. Additional
ADDRESS
Date ' Applicant 15 OR 20A,120V BRANCH CIRCUITS--NOTICE TO APPLICANT: H. after making this Certificate of CITY rel.No.
Exemption,you should become subject to the Workers' Compensation 1 TO 10 INCLUSIVE EACH
- PERMIT-, - I� _
provisions of the Labor Code, you must forthwith comply with such 41 OR MORE RAN H CIRCUITS
APPLICANT Q &7e G Q, -�K
provisions or this permitNSED.shall RACT RS revoked. ._ 41 OR MORE BRANCH CIRCUITS EACH /J }
LICENSED CONTRACTORS DECLARATION - --- - - ADDRE553 Z
I hereby affirm that I am licensed under provisions of.Chapter 9 150R 20A,208V T02]N LIGHTING EACH �.
(commencing with Section 7000) of Division 3 of the Business and CITYG' ?i l) L No D 3 Cf O
Professions Code,and my license is in full force and effect. RESIDENTIAL APPLIANCES UP TO 3HP
LICENSE OR '} / Class L�
Power Apparatus 8 Large Appliances REG.NUMBER ,5 3 � 1` 0
License Number Lic.Class Size 8 Type HP,KW,KVA,or KVAR DISTRICT NO. PR C D By
T IC/tc o L C� � 7� UP to 3'IncL _ _ Q�. lcGrt�.-.G✓
Contra tar Date '� LIJ
Over 3 to 10 Ind. CI-
PANTE -
Over 10 to 50 Ind. ff Z
❑ I am exempt under Sec. Over 50 to 100 Inct. _/ - y' VALIDATION
Over 100 -4
El for this reason 6Y
Services,Swbd.,MCC&Panelboartls
at
-- - 0-200 Amp.Under 600 V
S'anature _ � 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 _ _ AT___T y;L
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 Professions Additional Sign Branch Circuits d_U
Code): ^
❑ Misc.Conduits&Conductors --- - ,; r ,,-�.
ENS
I, as owner of the property;will do the work and the structure _ =s-
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) 1 C` ni- - -
'and Professions Code). ---- - - ® n;_I�r r n;,
7 t-,. ._
CONSTRUCTION LENDING AGENCY ={!'J
- +.GY=�
I hereby affirm that there is a construction lending agency for the
C ,ANC
performance of the work for which this permit is issued (Sec. 3097, PERMIT.FEE . . (Sub-Total)
Civ. C.) � -
' PLAN CHECKING FEE
Lender's Name - - _. `'T'? i. (I n a 1
PERMIT ISSUING FEE
Lender's Address
certify
I certify that I have read this application and state that the above TOTAL FEE pC !f-
information is correct. I agree to comply with all County ordinances
and State laws regulating Electrical wiring, and hereby authorize
representatives of this County to enter upon the above-mentioned
,property for inspecti urp s. 2C SEE REVERSE FOR EXPLANATORY LANGUAGE
7 —
NATUREOF PPLI ANT OR AGENT DATE