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/ � - -------_ ____.._ -----.-._ __ � --- � �-� -----:-_-:--_--;-� -- ,��. _ -- �WORi�:�COMPENSATIONDECLARATION 76a663 70i81 /���]�i` -�� � �-V�l ��tCTRtCAL PE�MiT���� � ,il he2by a(firm that I have a certificate of consent to self insure, cE-sosG �1 r �__,�.����._ �' " or a certific°3 of Workers Canpensation�nsurance,or a cc�titied - COUNTY OF LOS ANGELES BUILDING AND SAFETY # O copy there"�( c.3i00.Leb.C.) � PDli�y No.f�CAmP�M1y 'A FOR APPLICANT TO FILL IN - JOB '� .'1/y7 S` ♦ .❑. Certilied copy,is herehy fumishetl. . . EACH N0. FEE p���ESS LJ1/ . . :. • , New Residential 61dgs.8 Pools '� Certified copy is tileA-with �county�boildi inspedion 1 8 2-Famiy,SQ.FL S — 5 LOCALRV� 'f �� -• dCp2ft nt. ' �� ���.. , Multi-}pmily$q.FI. — NEAHEST. . .. . CROSS ST. � '� � Fesidential Swimmirg Poo�s ^ �� a ,L � . MPlkant . FIRM NAME � t/ � �����'-CE FICATE OF EXEMPTON FROM W RS' Outiets:Rec�L'ght�$w.L� ' MA�� d�� -�,� � �-.���COMPENSATION INSURANCE � � � �- , � nooReSs p .(Thts setflon ixed nol be eomplelad H the work Irwolve hy th First 20 �,permil Ie for ane huntlreA tlollan(5100)or lese.)� . Total No.� pdditionai � CITY .�L. Tel.No.G I Celtify that in Ita�performance of.the vrork fof which this permit ' _ . PLnN CHECK .is issued:1 shall'rot employ arry person in arry manner so as to aP���� �become subject to the.Workers'Compensation Laws.... L'ghting Fiztures� First 20- � AODRESS - - - � �- ' �- TotalNo. Additional.,, Date -� �Applicant �� � � � � CITY- Tel.No. .NOTICE'TO�APPLICANT::If,-atter makrt�g�this.CenifiCate of Fxed Appliances Not Over 1 HP � pERnniT Exemption,you shwN becom@ subiect ta the Workers Compensation . ._ Range_Heater_D W. _ _ ' AP���'�T � -provisions o(the Labor Code,you must Forthwilh comply wi[h such Oven_Dryer_W.FA._ ADDRESS � G� � �provisions or this permit shall 6e deemed rewketl. � , ..Top� _FAU _-W H._.. -��-- - � CITY � �� - � � Tel.N � - �� LICENSED CON7RAC70RS DC-CLARATION�...' . Hood_Fan _Other_ •1 hereby affirm that I am I"�censed uMer provisions of Chapter 9.__. . Disp.'--Room Air Cond. � .. uCENse O • l � (commencing with Section 7000)ot Divisbn 3 of the Business and — REG.Nunn / �" -�-- CM%� � ProteS&ions Code,and my licen5e is in full lorce and eflect. . . DiSTRIct NO. mOCESSEo BY PoNcr Apparatus 8 Large Appliances.� _.. ... . . � �... Size 8 Type HP,KW,KVA,or KVAR � ,Q . � License Num �,��$_.�ic,Class� ' -- � - -�"� � � ��- �� �� � . U. Up to 1 Incl. � FlNAL g / Over 110 101nt1. �A� �?j��% ALIOATtON � Conhactw Date___���L /. . . . OO Over 10 to 50 InG. Fl�q� U ._Q. I.am exempt under Sec. - - � Over 50 to 100Inc. .. By B.BP.C.f���hig f2�5�� �VE,,�� � . .- .. ..- . Q . .. } Services,Sw6d.M hc�s ' � � , � - � . . _.. - - -- .. . .. z _. . .._ . .. . . ..... ... . r � _ � ��bate(�-" nder 800 V Sgnature . " �� 201-1000 AmP.Untler 60 .. . .. .. . . ._ . .. . " ... .. -.. ......_�.-... . ._ .. . ._._ . ❑ . � Over 1000 Amp.or Over 600 V � Ezemption for Reg.MainL Elett. - ��� � � -—-� - -� - � - - . . - - - ' � - SINGLE FA6",ILY �� - - � . . .Temp.Povre[Pole 8 Appurtenances... _._ .. ... _.. _.._ _.. .... HONE OWNER•BUIL�ER�ECIARATION � Sign with One&2nch Circuit � I here6y af(irm that I am ezempt 1rom fl�Contrac!o:'a Lice.^.se L;rv+ q�iti0nal S' i orarxh C;rc4!s for t�e following reason(Section 7031.5,Business arW Rofessions"� '�' - - �-- � � � �- � � ;±� 6-5 9 R Code): ❑ � �Misd CoMuits&Condudors . . . . . ... ..._..- .. ..- . . - .�• � �.• �2. . I,as owner of the property,will do the work and the structure � is not intended or otleretl for sale 1Section 7044,Business.- Other(See Comptete Fee Schedule)_ ► ' � • �(��5 0 ... . . . . . ... .. ._ . . � ,aM Professions Codel. . . . .. .. CONSTRUCTION LENOWG AGENCY . ... .. __� • ^_4 3.5 0 u I hereby af(irm that lhere is a eonsinxMion lendirg agency for tho Q O� �_$'� perlormance of the vrork for which this permit is issued(Sec.3097, � PERMI7 FEE" � �" �' '-�� -''� � '� 15ub-7otal)�� ��- �3 � � ��� � � - - - � Civ.Q�. _.._ .. __ ...__.. - PLAN CHECKIN6 FEE. --.- . . . . . . -. .- ... .. ... Lentler's Name - . - PERMR ISSUING FEE _. . . _. .. �� . . . ._ .. _ _ .. . .... .. . .. Lender's Address I certify that I have rend tfiis appl'�cation aM state that the above ���� -.TOTAL FEE .._ . ._. . .. . . ... 3�D � . . _ . _ ___._.. . . . . . ... _.. information is correct.i agree ro compN with all County obinances xnd State laws regulating Electrical wiring,ard hereby authorize _. .. ... .. .. ._ ._. . . . _.... . . ._ _... iepreseM['wes of this Co nty to enter upon the above-mentioned � � proper fo inspection pu oses. C-� >�-+ .. SEE REVERSE FOR EXPLANATORY IANGUAGE� -� � . - - _. _ . ! !J �> . . . ... . _. __ _. ._ .. _..__ . Signa ot Permifl Date ' '. :.. .__.. .. r.•-�' �---- - ', , -- -�- -I-`,•--- -.�_._I._..i__i-,.� -1 .-I..—---,--r/,. `; : _ _ � ;', I � j � I: _ I ` i? � W� . i j` � ; i`,� �,•` �'�--; � . �y '`- , – s�� 1 ( I I'i��� I' �: ;— ; ;� ;� :.• � � f ; ,.— j.�— i�:,� � �,� j � �.:.!; �,.., � �„ � ' ;,� ��-, ; - � � ; ;�'; � ; i_�;,�- ; i r� i - i I � �����- ' '- I ;I{ .._f j' �- -� i-- - � i ' � i I j,�, i,.."!�� t,. .i ;. . �� � � � 1 I.' �_ I,t^ i_ .! i:. . i y. ; ; . i , '.�i .. 1 � . � � ' �7 'n C 'O T I]' C -i j • . I � ' � � ;�/ :� � C O � �� c o � r� � =. �. i' : {,� ,�n �' -� `m c z c� m � - � �� I' � � ' � � c� D (mn- �; (�� �' O � '- ' '� ; � p � � z o � :a - ' " . - z x a � � o ,- . : _ I.� p � � o � � ; - �: � r, m � o rn ! 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