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DECLARATION 76AM GPW(,2 91) APPLICATION FOR ELECTRICAL PERMIT
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I her0by alOrm lhet I have a cerbhcete of consent to self insure
or a certificate of Worker s Compensation Insurance or a certified COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV
copy thereof(Sec 3000 Lab C) _
Poo 1��ComPany I - FOR APPDCAM TO FILL IN JOB
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Certified copy is hereby furnished New Remdenual Bltlgs 8 PQo)S NO EACH FEE
i11 5 E LOCALITY I
❑ Certified copy is filed with the t nidi i 1&2 Fa N�ySO Ft NEAREST
`z klulb fame CROSS ST
teaklenbal Swimming Poole _ • - r ASSESSOR
MAP BOOK PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS Guests Rec —Light_Sw _ W1ErUME IC
COMPENSATION INSURANCE N I 1
Is Fret 20
(This settlor need not be completed(51 fwork involved by itis Total NV ADDRE95 117 s
permit for one hundred dollars(31000 or o Additional
or lase) i
I certify that in the performance of the work for which this permit r I CITY"--,4h e r TM No
to issued I shell not employ any person in any manner so as to
become subject to the Workers Compensation Laws Lighting Fixtures First 20 �PIANPL SOK
Total No Additional
ADDRESS
Date Applicant RESIDENTIAL APPLIANCES NOT OVER 3 HP
NOTICE TO APPLICANT It alter making this Certificate of CITY Tel No
Exemption you should become subject to the Workers Compensation OTHER APPLIANCES NOT OVER 3 HP
provisions of the Labor Code you must forthwith comply with such Power etas 8 PERMIT
provisions or this permit shall be deemed revoked Apparatus Large Apphancea
LICENSED CONTRACTORS DECLARATION Size 8 Type HP KW KVA or KVAR ADDRESS N Of
I hereby affirm that 1 am licensed under provisions of Chapter 9 Over 3 to tO lxl
(commencing with Section 7000) of Division 3 of the Buslness and CITU L1e,4q
Professions Code and my license is in full force and effect Over 10 to 50 Inc]
LICENSE
Over 50 to IDO Incl REG NUMa1BE C) 163 ' a...
License Number,', _1 is Class Over 100 DISTRICT NO � p m By 0
/� Services /
Swbd MCC 8 Panelboards Ii• OC �
Contract —`'`' S�1'11 T // pate J'( 0 399 Amp Under SOD V FI 0
❑
I em exempt antler Sec `400 1000 Amp Under Opp VTE tIv VALIDATION W
Over 1000 Amp or Over 500 V FINAL d
B&P C for this reason BRANCH CIRCUIT FEES
Dere ISA or 20A 120V Ughting or Recept z
1 To 10 Branch Circuits
Signature11 To 40 Branch Circuits
❑ 41 Or kora Branch Circuits
Exemption for Reg Mant Elect 15A 204 20 VV To 27N Lighting Br Cvosls 2
SINGLE FAMILY Temp Power Pole&Appurtenances ACCT.`.
HOME OWNER BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor a License Lew Sign with One Branch Circuit - M•1.
for the following reason (Section 7031 5 Business and Professions Additional Sign Branch Circuits ;303 2nd
66
Coda) 1 ITM
❑ I as owner of the property will do the work and the structure Misc Conduits a Conductors TOTAL 222 . 66
is not intended or offered for sale (Section 7044 Business Other(See Complete Fee Schedule)— , COTM �'
and Professions Code)
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the p
performance of the work for which this permit is issued (Sec 3097 PERMIT FEE (Sub Total) �97
Civ C)
PLAN CHECKING FEE OW�-OOOI 5/.2.5/93
Lander s Name _ - - - ^--
PERMIT ISSUING FEE a 99S'% 1 { 942
Lender a Address -
I certify that I have read this application and under penalty of puduty slate TOTAL FEE
that the above information is correct I agree to comply wth all County
ordinances and State laws regulating Electra wiring and hereby authorMe
repir mauvesh�Cou ems,u the above mentioned property
1 I 'On un —S--2-r—I T SEE REVERSE FOR EXPLANATORY LANGUAGE
BIatUTURE OP PE frTFE DATE