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� WOR�..��COMPENSATiON DECIARATION�`��� ^��-7IA667 10/61 ^�� �/j�j��.�
I hereby offirm�hm I have o certifimte of consent Io 5e�f �E-� , APPLICATION FOR ELECT.RICAL PEI.�UIIT . ,
insure,or a certi(icaie of Workeri Compensaiion Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY �9�' � �
or a te�tified copy thereof(Sec.3800,Lob.C.) . . I
� P❑ol�icy No. Company FOR AP�LIGNT TO FlLL IN q�pp{�55 � '
Certified copy is hereby l�rnished. New Residentiol Bldgs.8 Pools EACH NO. FEE �"�� N ;
a - LOCAUTY �
Cerrified copy is filed wirh�he county building inapeo- � 1 8 2-Family,Sq.Ft, f — E �N.� �
� tion departmem. . - Muhi•family Sq.Ft. — �ERp555T. ��Nu�
Da�O Applicont : Residential$wimming Pools OWNER OR �
FIRM NAAAE P� �L e / I
CERTIFICATE OF E%EMPTION FROM WORKERS' � � � � � �t • �
Outleta:Rec light Sw. ,S• T %G ��. �
� � COMPENSATION INSURANCE � � GQ a�DkESS �
This��etlon nNd not b�eom latsd IF ths wo�k lnwlv�d y� F"g�p �
I P 61' ; Totol No.�.aZ_ Addi�ional . . � CITV �N� Tal.No. �J
Ihs parmH is for one handrod dollan(1100)ot Ioas.) � . .
I terlify Ihot in the performance of the work for which lhis - APPLICANTK �
�'��_permit is issued,I sholl not employ any peraon In ony monner � - �
so as to become subject 10 fhe Workers'Compenwlion Laws. lighting Fixtures First 20 ADDRESS
To�al No.�� Additionol �
Dote� Applimnt•�FELC'C-%�IG pTV Tel.No. ,
NOTICE T-�T: If, oftar moking�his Certificote of Fized Appliances Not Over 1 HP PERMIT � '.
Exemption, you should 6ecome subjecf to the Workeri � Ronge_Heoter_D.W._ APotKANT �-� L�C' G
Compensafion provisions of ihe Labor Code,yoo musr lorth- . Oven _Dryer _W.M. ADDRESS � G� � �
with tomply with such provisions or this permit sholl be . Top _FAU —W.H.�
daemed revoked. - � � CITY N� �' Tel.No. _ Q
IICENSED CONiRACTORS DECLARATION � Hood _Fon _O�her_
I hereby affirm tha�I am licensed under provisions of Chap�er 9 � Disp. _Room Air Cond. _ C� ��UMBER 3 3s�a Closs.��0 .
(commencing with Section 7000)of Division 3 oF tbe 8usiness �power Appnrolus 8 Larga Appliances DISTRICT NO. PROCE55 D BY }
ond Professions Code,ond my license is in{uil force ond eHect. - . : p, �
� .J �1,,' � Size�Type HP,KW,KVA,or KVAR' u-t�� �
License Number ��7��� lic.Closs� - � � -�� FINA � � � � V
Up to 1 Incl.
Conimc�or���FLG�L`%�IG Dote a I7 Orer 1 ro IO lnd. DAT VALIDATION �
Over 10 to 50 incl. FINA ~
❑ I am exempt under Sec. Ove�SO to 100 Inc. BY , 6
8.8P.C.for thi3 reason � Over 100 . � v� .
_ . Servic .,MCC 8 Panelboards Z �
Da�e; m Under 6W V �� � � � �
Signat�re 201-1000 Amp.U�der 600 V
� Exemplion{or Reg.Moinr.Efetl, Over 1000 Amp.or Ovar 600 V �
SINGIE FAMILY Temp.Power Pole 8 Appu��enontes �
HOME OWNER-BUILDER DECLARATION � Sign wilh One Bronch Circvil � �� 6 Q 0 A .
I heraby offi�m thot I am�eaempt from ihe Controctor's License n�di!icr.cl Siyn 9ronch Circ!�i±s �
law for the following reason(Sec�ion 703I.5,6usiness and � � �. • e e e 7
Professions Code):
� Misc.Conduits 8 Conduttors
I,as owner of the property,will do the work ond the � o •F Q,�]5
structure is not in�ended or offared for sole(Sedion Other(See Comple�e Fee Schedule)_ , .
7044,Business ond Professions Code). - .� .���]j�; '
CONSTRUCTION IENDING AGENCY - � �� .� 7-_8 4 �
I hereby offirm thai�here is a cons��uction lending agency for
the performanca of the work for which this permit is issued PERMIT FEE - (Su6•Total) �� �� - � - . . . . .
�Sec.3097.Cfv.C.). � � �
, S«M/��MO�fl�✓� . � P�'0'N CHECKING FEE � � �� � . . _. . .
Lender'S Nome - - � � �
J / � wv PERMIT ISSUING FEE . . C �
. Lende:s Address /4�/9LMA C/9� � � �
� I tertify Ihat I have read Ihis applicotion ond slate thot the � TOTAL FEE � l�.7Jr .
obove information is correU.I agree ro comply wirh all County � � '
' ordinonces and S�aie laws regola�ing Elechiml wiring,and - . .
\ hereby ou�horize representaiives of thi Coonty to enler opon �' � �
�the bove-m d prop rty for in ection pu�poses. SEE REVERSE FOR EXPLANATORV IANGUAGE
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