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1057A (9)
_._ _, ! - WORKERS'COMY};NSATIONDECLARATION � ry•76A663 � A�.P�PLI�CATION� FOR. ELECTR'ICA:L P�ER/r\IT�. � � - j � , �� CE$O6G(2-50�) � � I herebv aefirm that l have a certiticate of consent ro se�f ` COI�NTY O�LOS ANGELES BUILDING AND SAPETY insure,or;i certificate oi Wurkers'Cnmpensation Insurunee,oc . a certified copy thereof(Sec.3800,Lab C) � � � � � � � .�� �. /�L`•-%:d/��,„ � /�/[r�a�NC'..��L� ����+�,:� FORAPPLICANTTOFILLIN JOB� /����,��� ����� . �YulicY Ro. ��l�:+.�� �ompanY � �,[�'F-ST- New Residential Bldgs.&�Pools EACH NO. FEE Ao�RE55."' � v,v`a(/'�i.�:` � � Ccrtified copy is herebY furnished. ',,� 7&2-Femily,Sq.Ft. $ _ $ LOCALITY���`��� '' � �, `+�Certified copy is filed with[he count buildin i Multi-family Sq.R. N ARES y g inspection CRO55 ST �� ,, � ��"4�department. Residential Swimming Pools OWNER OR�7� ,�����!' � � �' FIRM NAME �- •Data�� � ApplicanY)���L��"",/('l/� �7• ' Qutlets:Rec.�Light_Sw. MAI L ,y�n�r�„d���ll�j•�:�� . CI:RTIPICATE OF F.XEMPTION FROM WORKERS' First 20 AD�DRESS I�S�S.�C�77i ee'7/1�'+«� �" � � � COMYENSATION INSURANCE Total No. � Additional CITY"���7 f���� Tei No�-y7..� � } - � ' � P�AN CHECK,- ' a� (This sec[ion need not be completed if the work involved �� - APPLICANT� �� � �".".'�', ; V Li htin Fixtures First 20 �by the petmit is For one hundred dol(azs (5100) or less.) -. 9 9 qdditional .4DDRESS::��� <' �/� � � f � Totai No. � � Q . �! certify that in the performance of the work for which this ` CITY � p s Tel N a � ermit is issued,I shall not em lo Fixed Appliances Not Over 1 HP y ,.� �'7�/J� "1" �� �"' P p y.m�y person in any manner' - PERMIT �V� -� �so as to become subject to�the Workers'Cumpensation Laws. ' Range_Heater_D.W,_ APPLICANT �fi�,.��.� '�l('"' ..y�+ �� � - �Oven _Dryef_W.M._ ADOFESS �y.-� . � � �llute Applicant 7op _FAU _VO.H.._ � � Hood_Fan _Other— CITV --"" 7el No. � NOiICE SO APPiICANT:[f,af'ter making this Certificate of pisp. _Room Air Cond._ uCEntSE OR ��,��,r - � ,.f! ;�--� �Exem tion, � - . ..+G,r�,la�w Class 'J���~ ` V Y�u should �6ecome subject to Ihe Workers' -` REG.NUMBE .� � .Compensation provisiuns of the Labor Code,you must fnrth- ` Power Apparatus&Large Appliances DISTRICT NO. PROCESSED BV i �vith compty with such provisions nr this permit shall be � Size&Type HP,KW,KVA,or KVAR � ,j � deemed revoked. � . � �'� ./1_�Z�u,� � j � � UP to 7 Incl. '�J .. . 4 FINAL ! Over 1 to 101nc1. DATE � LICENSF.D CONTRACTOHS DtiCLARATTON . . G� �'� VALIDATION . Over 10 to 50 Incl. � .I hereby affirm that 1 am]icensed under provisions of Chapter Over 50 t0 100-Ina F�N'4� � BV 9 (commenci�g with Section 7000)of Divisiun 3 of the Busi- OVer 100 ness and PrnTessions.Code,and my license is in full furce und � effcct. ' �Services � � . ��License Numbe�.�����J`y Lic.Class.�'�-�„�,=1 0-200 Amp.Under 600 U �r �� 2Q7-1000 Amp.Under 600 V.� � Contnwt��f.�h`�/li ���f.�ate��'( ��1� • Over 1000 Amp.or Over 600 V � � . � HONI7S OWNEk-BUILDF.R iIECL,ARA'I'ION .Temp.Power Pole&Appurtenances - I hereby :�SYirm that I am exempt Yrom the Contractor's �Sign with�One 8ranch Cvcuit � i,icense i,aw for tne following rcason (Section zo31.5, Busi- """' � y "'�""'""`""' - ��:I';U�a`(H ness and Professions Code): �. l V Y v � ; ' � - 'MisaConduits&Conductors ����;��•';.�`°��Z � � � I,as nwner of the.property,will do [he work and the `Qther(See Complete Pee SChedUle)— � xtructure is not intended or offered for sale (Section ��'m .'2�;5� . - 7044,Business and Professiona Code). . � CONSTRIIC'C10N LM:NUTNG AGN:MCY �.e'o�e�'�[�-�Q x ��1 hereby affirm that there is a construcNon lending agency � . . � for the performence uf tLe work for which t}�is permit is pERMITFEE (Sub-Tota�l J' � 1-2 T 7'�H�� issued(Sec.3097.Civ.G). . ���(✓ . Lender's Name PLAN CHECKIiVG FEE (One-Fourth Permit Fee) �. Lender's Address PERMIT ISSUING FEE ��(� � � '. 1 certiPy th�t I have read tY�is application and state that the TOTAL FEE . /D . . � above informatiun is correct.I agree[o compty wtth nll CuimtY � � � . �� ordinanees and State laws mgulating Electrical wiring, and �. Itereby authorize representatives of this County to enter upon � � the ahove-mentioned property for inspection purposes. SHEREVERSP:POR EXYLANATORY I,pNGUAGE � � •� /q* �' . �s ..i .✓s^' .: .✓" fi✓ , Signa[ure uf Permitte Uate . ,r�,/ . - ' , . i ! I ;.. � .. .. .. I �. f I.... � ; , ..n � I � � � -� _ .� I � ; � . � �: j � , � �: � �: :� � � I, . . � J .l: i �, I, � I. . : . . �y ' �i � � � . . . . ' . �.-� �� i�: �,. j''. ' � — �a I-- -- � I ! '. , ;_ ` . , ., �. .. .. y ,, : � `', ' � � I � 4, ': � .,,. . Z .m: ,.C. ;� T � �, ` m � O � +� — O Z .,�. 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