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i ,. , I 'GJORKERS'COMPENSATIONDECLARATION �76A65J lUfB� AP��ICATIC�N �OR �LG��RICAL P�RMIT � � � I hereby affirm that I��have o certifimte of consent to self. CE-806G , � i inwre,or a cartifimre of Workeri C mpensation Insura COUNTY OF LOS ANGELES' BUILDINl3 AND SAFETY o/r�oj tertifi c�py 1 erejo��f�/qa c 800 Lab.C.y �� � � .� �� � � .. pai{c, 47�h 11nY ' ��. FOR APMICANT TO PRt�N � .. JOB �. � i CeHified copy is hereby fumished. . ;, � � New Residemial 81dga.&Poolr,���� EACH rvd. ,� FEE� � ADARESS ♦ r �oGaL�N r -Ce�tified��copy is filed with the couny building�inspea. 1&2-Family Sq:.F�. s — _ � , Y��'�,�Y n par ment. ///�����, . !1 rt.. . - Multi-ftlmlly Sq.F1. � — NEAREST � ,�i .. .,. � � 1) !f Retidantiol5wimmin Poold CROSSST, � V�S Dat �`I Ap� V �1..��0 . , 9 OWNEROR � , � - FIRM NAME � . I'i ',�. CE IFItATE OF EXEMPTION FROM WORKERS' ', - �putleb:Rec„�Light.�_Sw...r � -� ''��� ` �. .. , .� �....WMPENSATION INSURANCE � .�.� .. . AD�RESS �! -. ' (Th4�svci�an nead no1 b�tomplatod if th�work involvod hy � 7ofal No. � � Firi1 2q�. ... . . . CI1Y � i.No. r .. ' tha permH is ieq on�h�ndrod dollais(SI00).or lass.) � . � Additional � �� PIAN� HE K '� . ' 'I carlify tha�irv�the�performanca of ihe work fo/wbich�thls ` . � � � � � � �. . . , �� � qp T , � � � . �I permif is iuoed,1 shap aoi amploy any person�in any mannar �. � � � . . . .-.. . . . � , ' so os to�6acome�subject ro�tha Worken'Compensation tawa. ' Ughting Fixrures��� � �First 20�� ADORESS . � � : y.��- .. : ... . . �. - . . , . � Addilional. . . . '�. . To�at Na.� � � . CItY No. �. � Dare'' �pp�ican� � � � ` . ��� - Fised ApptiancesNot Over 1 HP pERMp --– — �. ' NOTICE-TO APPIICANt: If, after�making:this Certlfimte of � . � . � � ' qpp�i�qNT ' �. Exem tion;- ou shouid become�su6'ec! to��htr�Workers' �� � RO°9e!pae��f_W M.� AODRES • � P Y I ! '� Campeoau�ion provisions'of ihe Labor Code,you�must forrh- Oven y,� �, . ' wilh jcomply.with such�provisiona or this'permit shell be_�� .'�op�.��:.�FAU.�:�_.W.H:�—� � , � � . - - �� deemed revoked. � .-���.-� � ���� Hood,��.fan � �.,,,O�har_.�. ' CITY Tel.N . � „; ,� LICENSEQ CONTRACTORS DECLARATION'� � � . � � _ � . . . . UCE R._. . . '�. ��� �her�6y affirm thal�l am.licensed under provisiona of Chapfer4 � �Disp. _;Robrt!Air Gond: -_�'� -�� . REG.NUMBER- Clas. � (comMancing with Section 7000)of Divlalon 3 of the.Businesa �� � � .. . .:. �ISTRICi NO._ .. � . . PROCESSFD-8Y . p}„' , ��� l ce�efNu�iobeCode..an�license{Lic foi! rce an effecl. PoSizr 8 T pe H P�KWr KVAPPw'KVAR ._. . . . FIAAL. , �, /�(, . CC �' i � U l0 1 Intl . . . � Co tf�c n . �8.: ,�� Ovacl.to t01ncl: . .. � � . .*-�.Z.���3 . • VA IDATION� t= ; '.. ❑ � . Over 10 to 50 Incl:� FINAI � .. . .. .... ... 4J �' ��t am exemp�under Se.- Oatr 50 to 100 irx. � BY a ' � � . Servicea, f?ver 100 . .. . � � ... .. ! . .. � .. . .. . N f z � . ��Signature. . . . .. ��Dare: ..�.,..,� . . �1: 5wbd.,MCC 8 Panelboards� � � . . ....� . . � ; 8.8P.C.for fhia reason . . . . 200 Amp.Under 600 V � .. ... . .. . . �. . I , � � `Examption for Reg.Maint.EIetL �. . . Over 1000 Amp.�ornOvar 600VV, � ..... . .. ... .. .... . � , � i � . . . . .�SINGLE FAMIIY � . . ..:_ � . � � .. . . .. . . .� . _.. - � .. � � ' HDME OWNER-BUICDER DECLARATION . � '�-Temp.Aower�Pole 8 Appurtenonces- � � � iaW' Sign wi�h One Bronck Grcuif . , eby�affirm that 1 am exempt from rhetontracror'a Utense Addirionol SIqn�Branch Cirtuifa�'�. ��' ` � ���� " �� � � � ` ' for the following reason(Seciion 7031.5,Businass and � � � . � � -� � #�QQ ; � uions Code): ' . ... � � ; . ... 7 •.• I �.�� Profai � � '� � � � � �� Mise.CondWts&Canductoro �- �. �� . � . � . _ . ��i,aa owner of ihe propeny,will do the work and the � �• •�-$,p 0� � !slrucWre ia�o�intended or offered for saie{Sat�be � �� Other(Soe Complete fee Schedule)_ � ,��. � � � � � � - � . i 7044.Business and vrofessions Code). � . .. � O$� H—H H . . �� CONSTRUCTION LENDING AGENCY � . . . - - � � � � -� � - � �� � - � � I hereby affi�m that�fiere ia a tonstrutlion lending agency for ' - - � � � � � �. �. the artormonce of tha work�for which thi�parmit id issued � PERMIT FEE �.��' `�'� �:� � (S�ti'-TotolE � � � �-��� - - � - � � � ��� �- � P � (Sea�.3097;Civ.C.). � � � , � , .. .. . . �. . � . � . � - � . . I , . . . . � FtAN CHECKING FEE . . . . ;.: . . . .. .. . . ... .. . .. � . _. . . '�.. � Lenda/s Name � . � ... � . . � . . . �. ' � - � PERM11 ISSUING�FEE... �. . � . .. . . ... _ . ... . , .. '.. Lender's Address �.. � . . � � . . � . .. . . . � � - � . �. ���, {ceriify that t have read ihis application and srofe that 1he . 10TA1 FEE , ... . ..._.. . . . .. .,� ; _. :_�.. � . .. . . . . .. . above informa�ion is correcr.I gree to compiy with ol{County . � � . . . . . , . . � . . � . ordinances aad S�afe laws. g ti Eleclric wirin9,and . _. . . . ....... � . �� .... . . . .. . . . ... � ��, � hereb rize repre t ti his Cou o anter upan � , , � � � � . . � �. . � � � � � . .. the ti e e npectio urposea. • � SEE REVERSE FOR EXPLANATORY LANGUAGE 6 . Signaf e o r d e. � Dale . . . . .�.. . . . . � � � �.. i . .. . . .. . .� . - � . � . . . . � - , . . . . � .. . i ... - . .. . . . ' ,. .. . � . , ... . _ . . . . ._,_ . ... . ... . , .. . . , `1 , � _ , . � \ � ,.�� :�-<< � � � � _. � . 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