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*43.na I have a cerf"tG ofDECLARATION CE 863 0181 APPLICATION FOR ELECTRICAL PERMIT
e-0sraby ativm that I have a cerbhceta of consent to self insure, CE 6060
or a certificate of Workers Compensation Ireurence or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereat(Sec 3800 Lab C)
Polly No Company FOR APPLICANT TO FAL IN JOB / �� p] ,
❑ Combed copy a hereby furnished , New Resldenhat Bldgs & Pools
EACH NO FEE �� C-. �C..
❑f Certified copy is filed with the county building inspection 1 8 2-Family Sq Ft �k 30 $ — $ LOCALITY
i department i Multi-family Sq Ft NEAREST
•
Residential Swimmmg Pools CROSS ST
Date Applicant OWNER OR p j/'
,' FIRM NAME R• D�/Y J
CERTIFICATE OF EXEMPTION FROM WORKERS � S,w, � r� ANS p�
Cutlets Rep Light
COMPENSATION INSURANCE 1 11t Ss S U
7TIs section need not W co feted H the work InvoNetl b the _ Fust 20
( Y Total No Addapnal '''— ' '' TY- L `GIT Tel No
art
permit lo for one perform dollars($100)or leen 1
,I cerhN that In the performance d the twrk for Which this permit PLAN CHECK
Is Issued, 1 shell not employ arty person In any men, r so as to ,
become subject to the Workers Compefisetlon Lew Lighting Fixture s� ��77 Fust 20 is ADDRESS' - '
Total No —L Additional CRY - Tel NO
te� Apgcart
Fixed Appliances Not Oren 1 HP • '
, NOTICE TO APPLICANT If after this Certificate of gPERIMIT
Exemption you ahoud become eu o the Workers t Rerlga_ Heater— DW _
pfpWlsions of the Labor Code moat forihnth comply with such Oren _ Dryer W M ADDRESS k .5;0r `/
provisions or this pert shall be deemed revoked Top — FAU _ WH
,LICENSED CONTRACTORS DECLARATION CITVK 781 p�
Hood — Fan Other—
hereby affirm that em licensed order Provisions of Chapter 9 Dep — Roan Air Card '� EOR Class
(con menci g with Secbon 7000) of Division 3 of the Business end PEO NUMBER Z '3 G
Professions Code and my license is in full force and effect Power Apparatus& Large Appliances USrRICT�• P SSED B
. p
9 Size& Type HP KW KVA or KVAR oQ R
License Nu'm(/be�Ar��I/y�^r�J��,// Lia Class `-� Q Up o 1 Incl FINAL - `•'
Contractor��"'�+ �'L �Bu�Date�—I r+ - Over 1 to 10 Incl DAA •VALIDATION 0
Over 10 to 50 Incl R U
❑ I am exempt under Sec Over 50 to 100 Inc BY - µ�
B&PC for this reason a Over 100 4
Vl
Services Swbd MCC& Panelboards
Date 0-200 Amo Urde(�r800 V ,7
Signature 201 - 1000 Amp Unde800 V a
❑ over 1000 Amp or over 800 V
A(GT.*
Exemption for Flee Maim Elect 3307 93.75
' m
SINGLE FAMILY Temp Power Pole& Appurtenances 1 ITEM'
-^
HOME OWNER-BUILDER DECLARATION Sgn with Ore Branch Circuit
I
the fhereby cl affirm
reasohat I onn(SSec4on 7031 5e Business Licerse Law Professions Addrtonal Sign Branch Chants T01 AL 93 - 75
Code)
❑ Misc Candurts& Conductors C HECK 93.75
as owner of the property,Will do the work and the structure CHAP{GE ,w
e not intended or offered for sale (Section 7044 Business Other(See Complete Fee Scheduie)
and Professions Code)
CONSTRUCTION LENDING AGENCY -1p6-1 f0a :115/9
1 hereby affirm that there is a ooristfuctian lending agency for the
performance of the work for which this part is issued(Sec 3097 PERMIT FEE (Sub-Total) 1259 4 AM11-07
Civ C)
PLAN CHECKING FEE .-
Lenders Name I I i
PERMIT ISSUING FEE
Lenders Address
I pertly that I hate reed this application and state that the above TOTAL FEE
information is correct I agree to comply With all County ordinances
and State laws regulating Electrical wiring and hereby authonze
representatives of IN my o enter upon the above-mentioned
rty fa
propereps �r1 purposes - SEE REVERSE FOR EXPLANATORY LANGUAGE
i X&
%7664Permittee - Date ,