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WORKERS'COMPENSATION DECLAflATION 76AE63 tOtet APPLICATION FOR ELECTRICAL PERMtT L, 1 I hereby affirm that I have a certificate of Consen[to 5elf insure, G6806G or a certil�cate of ZYorkers'Gompensation lnsura�e,or a certified COUNTY OF LOS AMGELES �O BUILD�NG AND SAFETY U copy ihereof(SeD 3800,Lab.C.) Porcy r�o. 1003782 �mpa� STATE FUND F011 AVPLICAN�TO flLL IN ,roe ❑ Certitietl copy is hereby Furnished. EACH NO. FEE AD°�Ess � 24283 BRECKENRIDGE I.OT 38 � Nevi Residential Bldgs.8 Pool 1 8 2-Famil 3291 y _. s LOCALRY eena�ee�ovv �s f�iea w��n me county building inspection x sa.F�. AIAMOND �art;+�nt. „ -� MuNi-family Sq.FL � — NEAREst ��d^�•f E & D ELECTRIC I C. ResidentialSwimmingPoois �+osssr. Dale Applicant � OWntER o� ' cx��eNnMe M.J. BROCK & SONS IN � CERTIFICATE OF E%EMPTION FROM WORKERS' OuUets:Rec_Li9ht_Sw._ ` - �\ MA�� P.O. BOX 3SO - COPdPENSATION INSUflANCE � - �nooqess (Thia aectbn nead not 6e completetl H the work Irnolwd by tM1e F'ms!20 pqmit Is Ior one hundretl dolian(5700)or kss.{ Total No. Additional GTY . - $RE(� Tei.No.SZy_81 0 I,Certily tha[in the performanCO Of the Wofk 10f Which this permil � . FLAN CHECK � Es issued,I shall not employ any person in arry manner so as to p�f11�M become subject to Me Workers'Gompensatlon Laws. Lighling Fix[ures . Firs!20 � AODRESS � Total No. Additional , ,/'�. � � - CfTY .. . . Tel.No. e App!icant � � Fixed Appi�iances Not Over t HP ..JTICE TO APPLICANT:�II, afler making ihis Ceridicato ot PEr�nnir E & D ELECTRIC INC. E:emption,you should become subjecl�o the Workers'Compensation . ��^9e�Healer_DVl. _ . ����NT prpvisions of the Labor Code,you must torthwith comply with wch Oven,�ryer_VJ.M._ qDDRESS 319 M � provisions or this permit shall�e deemed revoked. 700 ---FAU _W.H._ . LIGENSED CANTRACTOFiS�ECLARATION . - Hood—Fan _Other__ C1TY � � 1.TPLAND� � �� Tcl,Tfo.4(y(-2231 I here6y alfirm that I am licensed uncler provisions oi Chapter 9 Disp. ._._.Room Air Cond. _ ucENse oq (commencing with Section 7000)o(Division 3 0l the Business and REG.IJUMBER 422589 � c��s. Professions Code,and my license is in full fOrce and effect. power Apparatus 8 Large Appl'�ances -� . DiS7flic7 No. pROCESSED BY Size 8 Type HP,KW,KV�,ot KVAR I O 0. � ucense Numher 42Z589 �c.C�ass C�lO Up to 7 Incl. FINAL DATE �7 Contractor E & D ELEC• p����j�—Cg�— o����o�o�^��. / VALIDATION 0 ❑ 6�r 10 ta 50 Incl. F�Nq� �J U 1 am exempt under Sec. Over 50 to 1001nc. gy �,�! � B.EP.C.br this reason Over tU0 V . Services,Swbd..MCC 8 Panelboards � � ' � � � N Date: 0-200 Amp.Under 600 V z Signatum 201-1000 Amp.llnrkr 600 V � � ❑ Exemption for Reg.Maint,Elect. Over tOQO Amp.or Over E00 V ; '�O Q 7.9 A �'�^ � SIf1GLE FAMi�Y Temp.Power Pole d ApOurtenances � �� • � ' +2 � . - HOME OWNER�BUILDER DECLRRATION � I ° � Q Z.��A 1 here6y alfirm lhat 1 cm exempt from the Con!ractoPs License l.aw Sign with One Hranch Circuit �. for the following reason(Section 7031.5,Business and Professions Atldllional Siqn&aoch Circuits .. .. e. j(�2,� L� codel: 0u24�-S7 ❑ I,as ovrner of the properry,will do lhe work and ihe struclure Misc.Conduits d Canductor5 - � � � � -� is not iM.enCed or cfferetl tor Gaie(Seetion 704a,8usiness . Other(See Complete Fee Schetlule)_ � antl Prolessions Code). '. � � � � CONSTPUGTION LENOING AGENCY � . _ . 1 hereby afiirm Ihat lhere is a Construction tentling agency tor the � performance ot the wwk for which fhis Cermit is issued(Sec.3097, p`RM7T FEE � (Su6-Total) 13�. /� -� -- �� � ' Civ.GI. . PLAN CHECKING PE@ �- � � � �� - . Lender's Name - PERMIT ISSUING FEF � . �LO O . - �endcr's Adaress 7.42.14 I certiy that I have read this applicalion end state that the above TOTAL PEE . , ' � inlormation is carect.t agre=to Camply with a�i County ordinances �� � antl State laws re9ulating Electrical wiring,and here6y autYrorize . representatives of ihis County Io enter upon the ebovc-mentioned � ' - - � - H� r inspection parposes . �����)n n n /�/��'�+1� J'� .SEE REVERSE FOR E%PLANATORY LANQl14GE . . . . . ... ;�1t i i 'x� f ^� Si aWrQ a Date � ..-� .�..,,.. .Y � .. _.... ... :-_ , . . . �, � . . , .. , • � , '.: . � � .. -,.... .� �' . .. . ., � ... .. . ... . ... .. .. _.. .. ..,�. .. . . " ' .... .. . � _ . , . .. � .. . _ .,C?:., . .,. .. . ,.., _ . . . . _. , i.. . . . . . .. . .. . .. . . ,. � � '� . -.. ._._+. . .. _ ___,_'--•' ' .'-'.. ..._'-' '•" '-.. ...__...._ _._._ .__" .. .. __._._....� _�._ .. . . .. . I � ..,. . .. .. i.. . .. . ... INSPkCTOR'S� . ,.. :� APaROvuS ; -- Dn7E '� ��" � - - --` �---�-�OWNER•BUILDER DECLARATION.��� ,�,' � '- . .. SIGNATUR[- - - �.. . ._. .� �-.. - 7EMP.POWER POLE - ..i�l�i�� � - - � ��'�.`� � � I hereby affirm that I am exempt from tlie Contractofs License � ____�� .. . .. _ - � - - � � � _.� Law lor�the lollo•.ving reason(Seetion 7037.5,Susiness'and � UNDEASLAB NlOfiK '� ' �� _ . ... �..- _..�.___ ______ _. � � � . �, Prolessirns Code):Arry cily a counfy which�equires a pomiif --"�---� '�'' � ;i`"t�COR;i2Cf,81fel, /OVe,dMil07'Sh,of f !�,�ry StlLC:NC, O/ �-— -- �oucH coraouir _ ___ ., .,.. .. ,. �nv msr prr j 5 r�,,�� ;�" � � � -�� -to Its7ssua�ce,afso icquims Lhe npplica�rt fa�such pcimit ta file �_.__'.' . _ . . ,VIIAING , � Q�� -� � , , . , � a signed sta!emenf lhathe is lice�sed pusuan;to.fhe p.row'sions -----" -�-'--'- --"----FlXTURES--�"�� � _ � ; 01�hc Crnhxror'c�Ckense Law(Chap!cr 9 feommencing with �� :-r;�_..<-;� .'.: ' � �. . - - . .._ . ..-. . - . .. � ., ! =���.Section 7000J o/Dtvision'3�.of.(hc Qusiness and Professrrns ' � ' -"-" �� "---��- �-���- - � " -�-" - � � � Codcl a-thal he'is exempt-lherelrom�and!ho Wsis/a^�fhc -��` ---� `-----.... . ._.. .f'0�7ER AUTHOF71ZE0,. � , � , ' �� allegd c.mmption. Any vlol�Npo ol Sectipn 7031,5 by cvY i--.--------------- -UTIUTY CO.�NOTIFIED �i . � { �.. � . � ��.n6canf fa a permit sublecfs 1he appNeanf Io a'ciN!penalv ' .._..._' _ FWAL -_._ ./;y(j('1'p11�YD)It._ . . . ._. , ., . � � d of rtof mare than five hundred dollars(55001.'�� � � � '�-, ; ,,i � � � , � "� _. ,.�, ' ❑I,as owner of the properfy will do the vrork,and jhe ;_ „___ NOT[s __ __._.. � �• � � � .structure is nOt iniCntled or offered for sale. .. . ... . _ _ .._ ..._ . � . . . . � ,',�f �...... ' . . ., - ' .. - - , � ,, � ��, . .- -(See.704a,f3usiness aad An�essions Code.�'7he Con✓aa....., L_�_----�-�'-� - `- �_. _� .,. , , ' - liCens^Law docs nOf a,opty fa an ownCr o1 prcperYy wDo bui�tls ' ^� � f�.-.' -�'_`!:� ' � ' � � � �- � - - � � ` � a impiwes lhcreon,,i�tl who does sueh wcrk himse(1 prwided . _1., .u..,. ..... � _.�.. .. . �., � f .. .. , . ... � (hat sUch'vnprOvenrents arc not inf^ntled or ollcred lor S�le.Il, t. �-- - . � , ..., . � . ; bowever,�the bul7drng w impro✓emeM is-sbld witnin one year ol � , � � ... �� '��eanple�ion,fhe a•mer-bui�dcr r�il7 ha�fne burcicn of proving lhat , � � ... � . ., - _.._._..... ...__ .. . : �_...::J._.._._.- � _.... . . .. , ..............__.�..""'�'""'" "... .. - � . . �- . . � �� he drd not bu.Hd or lmprove Por the pu�pose of sale.l � �1.// i}j � „ � „ ' �� . — --- _ _. - , . i , ._ .� i ` ,, _. _ _ _ _ _ � _ - . ,.I am exempt under Sec. , •-�� '---- ---_.-_.__�_.._.. �. � � . _. _ � _ . _ .. _ _..__ . . . . �.. . .,�. .,.... , . , �, . . .` -. _. .. •... ._ _.i ' -- -_..... ; - , _ . i . __6&P.C.for this rea;on :: , . . .. . ,�_ . ,,. .. • • � ._. ___ _�' _.__ ._ r..�� . � .__. .. _ .. � �. "---�-- � . . � ,.:. .. , : .. .Date - . . . . { i . ' , . �. , ' ' - � � - � Owner _ . ___. .. . . ___. :. . „ . ,.�, . . _i.. . . . .. . . . , . �i- - --- � - - . ' . .. . . , � � � ..,: �r �. . . , . . .. , . , ' ` _' . _. . .. . . .. _ ;� �� �`�' .