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� �� N'ORICERS COINPPNSATIpNlIECLARATION �� 76A663 � A�P`�CAT�OF4 FVR E�GClT*.�AL PERf7iIT
CE-606G 1�-801 �
1 hereby af�rm that l have a cen�t�care ot consent to self COl1NTY OF LOS ANGELES -�BUILDING AND SAPETY . �'�
1 insure,ur a certificate oF Workers'Compensation InSurante,or
� a certi�ed c�py thereof(Sec.3600,Leb.C.) -
� FOFl APPLICANT TO FILI IN JOB ,�A /�,
PoljCy COtnpany EACH ND. FEE ADDRESS OdV ��'C�G�
' New Residential Bldgs.&Pools
ft � .ertified copy.is here6y_[urnished. 1&2•Femily;5q:Pt. � — s LOCA�I7Y� �;f/
� Multi-family Sq.Ft. — AR ST.
Certified copy is fiied with the county building inspection CAOSS ST �
department. Recidential SwiMmirg Vools F�RM NAME
g AD�RESS . �D.3O
Date � �Applicant, /�d��/�l.Q/� Outlets:Rec._Ligh[_�'Sw20
CERTTF[CATE OF EXEMPTION FItOM WORKERS' Total No. Additi0�a� aTY Teti No. }a
. COMPENSATION INSURA3VCE PLAN CHECK t'
APPUCANT �J✓ (pj
(ihis section need not be comyleted if the woek imolved
R by the permit is for one hundred dolius(ft00)or IessJ Li9hting Fixmres First 20 aooaEss � S [[
. Additional Q
� TOtel Na. . CITY��1r� 7el _ �� h .
� I cutify that in the performance of the work fm which this Fixed Applieoces Not Over 7 HP U
permit is issued,I ahatl nnt empioy any penon in any manner PEAMIT �
� so aS to become su6ject to the Workers'Compensation Laws. Range_Heater❑_W._ APPLICANT N
i Oven _Oryer_W.M._ nDDRESS �y� Z
� Date Ap0licant Top ._FAU _W.H.,_ CITY Tel No. s
� . � Mood_Fan _Other_ � /���/ -
S� REG.NSUMBEF 0�7� Ctecs G� 7� �
NO'LICE TO A!'PLICANT:If,after making this Certificate of Disp. _Room Air Cond._
1 F.xem0�3on, you 9hould become subject to the Warkers' PPO ESSED B
3 Compenaation provisions of the Labor Code,y�u must frnth- Power Apparatus&Large APpliences oISTa1CT NO. �
; with compiy with such provisiona or this permit shall be
! deemed revoksd. Size&Type HP,KW,KV A,or KV A
� Up to 1 Incl. FINAL
E Over 7 to 10 Inc�. DATE I "$�� j VALIDATION
� LICENSED CONTRACTOR5�DECLARAT[ON Over 10 to 50 Inc1.
� FINAL
� I hereby affirm that i am]icensed under provisions of Cha(rter Over 50 to 700 Inc. gy
9(commencing with Section 7000)of Division 3 ot the Ausi- Over 100
� ness und Professions Codq and my license is in full force and
^ eifect. ? . A Services
's License Number�/���7 Lic.Cless �-�' r � 0-200 Amp.Under B00 V
� ��_��' / 201-1000 Amp.tJnder 600 V
� ContracMa���ate �/ ` � Over 1000 Amp.or Over 600 V
S HOME OWNER-BUILDER DECLARATION Temp.Pawer Pole&APpurtenances
� 1 hereAy afCvm that I am excmpt from the ContractoPs Sign with One BraaCh Cirwit
j Additional 5ign 8ranch Circuits �j�-� � 1� ��
� License Law for the fotlowing reason(Section 7031.5, 8usi- �
ness and Protessions Code): . -' • ° �
Mise.Conduin&Canductors
� 1, es uwnec ot the property,will do the work end Ihe Other ISee Complete Fee Schedutel— �I;� ,.. , `.�
stmcture is not intended or of(erod for sale (Section _ _
7044,Business and Professivns Code). �N .- �. . . �
CONS7RUCTION LENDING Al3ENCY .'
1 hereby affirm that there is a construction lending ngency
for the performance uf ihe work for which [his permit is pERMIT FEE . (S4b•TOtal) , :�'�C��`�� 1
issued(Sec.3097,Civ.C.). �
Lender's Neme PLAN CHECKING FEE IOne•Fourth Permit Fee)
1 LendePa Address pERM1T ISSUING FEE
!certify that I have tead this appiicatton and state that the TOTAL fEE �
� above information is correct.1 agree to comp�y avith all Courtty
ordinanees and Stste laws reguleting Electrical wiring, and �
hereby authorize repttsenta[ives of thia County to enter upon �
the above-mentioned property for inspection purpases. SEF.�REVERSE.FOR E%PLANA20RY LANGUAGE
, S. /P/
Signatute of Permittee Date .
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