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�RKERS'COMPENSATION DECLARATION --� � -i�omio0�ti-e�e.------�-� � � Q
,,;�a(irm tho�I huve a cerlificale of�a�5e�,,0 5e�� �E^� P►rruc.�►i�v�����c ELECTRICAL PERMIT
.te,or a tertiiicate of Wo�ken'Compensauon Insoronce, COUNTY OF LOS ANGEL�..i � DEPT.OF PUBLIC WORKS
,i o certified mpy thereaf(Sec.3800,la,(b./C-.)�^ � - I
/PO��ty NO(L�L.[�Comppny Sl'a/Y'�`�� . FOR 11PPLICANT i0 FIIL IN JOB t� p
Certified copy is heieby furnished. .. New Residem�ol Bldgs.8 Pools EACH � NO. fEE A�oee55 J.3� r d p� !�.
Cerfified copy is filed wilh-ihe coumy building inspec- 1 8 2Fomily,Sq.Pf. S — 5 LOCAIIN ��
; fion de artmenf. . M�Iti-family Sq.Ft. — NEAREST
� � l. Residential Swimming Pools CR055 ST.
�Dote A licont � O�'''NERoa '/� I
\��� PP FIRM NAME� �.t�/�y1CJ �r.
ERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec '�'P'�� �
�Lighl—Sw._
COMPENSATION INSURANCE aD�RE55 . � i (J�O
� tThis s�ciion navd not bo campleled�i the work(nvolved by Firsl 20 CITY �. � r Tel.No.
the psrmif it for one hundred dollars(SI00)er I�ss.) Totol No. Addiiionol �A�/r' � S
PIAN CHECK .
I certify that in the performance of the wark for which this APPLICAM
permil is issued,I sholl not employ any penon in any manner . �� htin Fiztures First 20 ADDRESS
so as to become subject to�he Workers'Compensation laws. 9 9 '
� � Additional�
Daie � � Applimm � Torol No. GITY Tel.No.
NO110E TO APPIICANT; If, ofter makin Ihis Cerlificate of Fixed Appliances Not Over 1 HP PERMiT i _ J� )�
9 Ran e— Heatar—D,W._ APPLICATIO (n(C(S /'C �Q /iy�
Exemption, you shouid become subject to ihe Wo�kers' 9 .
Compensation provisions of the Lobor Code,you must(orih- Oven —Dryer —W.M.— ADDRE55 Cr�o� ��
with comply with such provisions or lhis permit shall be Top —FAU —W.H.—
deemed revoked. Hood —Fan —O�her— CITYN, �I iel.No„SIi^''Gt�-�I�
� IICENSED CONTRACTORS DECLARATION LiCENSE Ort Uccr�
1 hereby affirm that I am licensad under provisions of Chapter 9 Disp. _Room Air Cond. — REG.NUMBER t J J Class �CO
(commencing with Sec�ion 7000)of Division 3 of�he 8usiness power Apparotus 8 Lorge Applionces - DISTRICT NO. I PROCES BY Y
and Professiom Code,ond my license is in full force and effec4 �� a
L/ �/ Size 8 Type HP,KW,KVA,or KVAR d O
License N�mber `��'L Lic.Class � FINAL V
Up to 1 Incl.
�G� 2� ;� Over 1 to 10 Ind. DATE �',-�2 90 VAIIDATION Q
Cont�aUoi Date Over 10 m 50 Incl. / H
❑ ' FINAL y V
I am exempt under Sec. Over SD 10 100 Int. gy �%� W
B.BP.C.for this reason Over 100 � a^•"-� a
�- � � Services,Sw6d.,MCC 8 Ponelboards , � � --
Date: z
0-200 Amp,Under 600 V
Signafure 201-1000 Amp.Under 600 V
Over 1000 Amp.ar Over 600 V �
� Exemption for Reg.MainL Eled. - . �
SINGLE FAMILY Temp.Power Pole 8 Appurtenances
HOME OWNER•BUILDER DECIARATION �
I hereby affirm 1ho1 I am exempt from the CoMrocto�i license Sign with One Branch Circuit `�$�9�
Law fot the following reason(Sectian 7W1.5, 6usiness and addi�ionnl Sl�n Rrnnch Circuits
Professions Code): � �� � ' ' •Z
❑I,as owner of the property,will da the work ond ihe Misc.Conduils 8 Conductors � ' • � �.�Jc '
stractvre is not intended or offe�ed for saie(Setlion 7044, . Other(See Comple�e Fee Schedule)_ '
8usiness ond Professians Code). ' • ° � �.Z J�
CONSTRUCTION LENDING AGENCY ��� �_8 8 '
I hereby offirm that there is a construction lendfng ogency foi �
the performance of ihe work for which this permit is issued PERMIT FEE (Sub-Total)
(Sec.3097,Civ.C.�. , � �
. � �. PLAN CHECKING FEE
lender's Name 1�
. PERMIT ISSUING FEE
Lender's Address � �
I cerliiy Ihol I have read this application and state Iha1 the TOTAL FEE
a6ave information is correct.I agree to tomply wilh all County � �
ordinonces ond 51ote Ipws reguloting Eleclricol wiring,ond - �
hereby aulhorize represematives of Ihis County lo enter upon . . .
the above- ntianed propert for inspetlion puiposes. � SEE REVERSE FOR E%PLANATORY LANGUAGE
�f� A� z �S
Signature of Permittee � Date - �s
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