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1071A (5)
• . � • • ■ y ■ WORKERS'COMPENSATION DECLARATION 78F683 1D/et qppLICATION FOR ELM`�r■ /�p��/{y��/��GpRR T � 1 hereby affirm that I have a certilicata of consent to self in5ure CE-eoeG r r��j�((7 ��� �f l■ 1 or a certificata oF Workers'Compensa�' surance,�rnf' COUNTY OF LOS ANGELES q�M�����r� A T COpy thereof(Sec.3800,Lab.CJ � � �"/T'V PoliCy No.���� � Cqmp8rry FOR APPLICANT TO FILL W , J08 �v EACH NO. FEE ADORESS „/� .O�Tp �Certified copy is here6y furnished. . , .,, , New Residential Bldgs.8 Pools � — LOCALITY � Cert'f d��c �� is filea�wi!h ihe C nty i ction 7 8 2-Family,SQ.FL � — S � � Mulfi-f3mily Sq.Ff. NEAREST ' . CRO55 ST. � Date Applica Residential Swimming ; p�,miEq pq . ✓J� FlRM NAME LG ' � CERTIFICATE OF EXEMPTION FROM WORKERS' � putlets:Re�—(CLi�ht Sw. I � MA�� � � �� - COMPENSATION INSURANCE ��' � � nooaess (Thls cactbn nead nol be completed N tha work Involved by the �� Frst 20 �RY Tel.No. permk is(a one hundred dollat8(5100)w Ieee.) � Total No. Additional G PU1N CM J certify that in the p0rlormarxe of the work forwhich this permit � � � ` � - ' ppp���qM ' ""�"�� PP .Is issued,I shali rw[empby�arry person in ary m2nnef 30 a4 t0 �become subject to the Workers'Compensation Lav+s. L'ghtirg Fiztures First 20 - - ADDRESS- - - ' '"' � - ' � � Total No. Rdditional__ ���, - Tel.No. Date � � � Appl'�cant ' � Fxed Appliances Not Over t HP pERMiT NOTICE TO APPLICANT: If, after making Ihis'Cedificate of Ap�i�M /� 7 EzempCqn,you shouM become subject to the Workers'Compensation - Range_.Heater_D.W. _ _ _ _ - povisions of the Labor Ca1e,you must forthwith Comply with such Oven_ �ryer_W.M._ AODRESS � provisions or this permfl shall be deemed revoked. , _ .Top �—�FAU _ W,H.-_��� -� � - - CITY Tei.-Fio. �Z? . - � .•L10EN5ED CONTRACTORS DECLARATION Hood_Fan _Other_ ��I here6y affirm that I am licensed uMer provisions of Chapter 9 �� Dis —Room AlrCond. _ uCENSEOR / _ ._ ��s (commencirg with Section 7000)ol Division 3 of lhe Business arn1 P� REG.NUM�ER Professions Code,and my license is in full force and e1FecL . Power Apparetus 8 Large Appiiances DISTRiCT NO. PROCESSED B � Size 8 Type HP,KW,KVA,or KVAR � O License Numb Lic.Clas's` � -�� � Up to 1 ir�cl. � � - FINAL ��1 (� V � " . . Y _ . Ove�1.t0 10 InCI. ,. DA� y p�Q l_ . _ _ _. VAUDATION. . � � Contract Date Over 10 to 50 Incl. U FINAL _❑ .I am exempt under Sec. � Over 50 to�100 Inc. - gY � �-—� - - �- - a ' Over 100 � B&P.C.for this reason ._ Z Services,Swbd.,MCC 8 Panelboards� � � � �� �� � � - � - � � � � ' �� � �Date: � �- 0-200 Amp.Under 600 V . Signature 201-1000 Amp.Under 600 V � � �� � � � �� � � � � � -� �� ❑ " � �� � � � ' Over 1000 Amp.or Over 600 V Exemption tor Reg.Maint.Elect. � �� 0 7,��{1 - - - - SINGLE FAMILY� - � Temp.Pov✓er Pole&Appurtenances . .. . . . . _. #.��•�'��'Z � HOME ONMER-BUILDER DEGLARATION Sgn with One Branch Circuit � I hereby afiirm that I am exempt 1rom the Contractor'S LiCense Law _ .AddiCron21 Sion Branch Circuils for Ihe foibwirg reason(Section 7031.,,,Business and Frcfessions �-- �-�� � �- � � � � ��� � ��i��ys� Code): ❑ I,as owner ol the will do the work arM tho structure Misc.Conduits&Conductors - � � � � � � � �.�!2�J,Jr�� �O�rtY' i Other�See Complete Fee Schedule)_ is not iniended or ottered tor sa.e(Section�oa4,Business . ► - p�,Q 5'�8 9 and Pro�essions Code). CONSTRUCTION LENDING AGENCY � �- - � � - - - �- I here6y affirm that there is a construdion lendiry agency for the per}ormance of the wolk for which this permit Is issuetl ISec.3097, pEFMR FEE � -' (Sub-Tofal) - - - - -"- �" Civ.QI. �PLAN CHECKING FEE�� - � � � - � �- ---� - - - - Lenders Name � PERMIT ISSUING FEE � � �� - - -- � -- � �-- �- - Lender's Address '— I certify that I have read this application and state that[he above .TOTAL FEE _ . . . ._ . . .. .... , . '.._.. ..... information is cw2ct.I agreo to compty with all County ordinarxes � arM State laws regulating Electrical wiring, and hemby authorize_ _ . . . . . . . .. .. _ ' ,. . ..... . - ... . _ ._ . .. .. . .. .. represenlatives of this Co nry to en!er upon the hove- ntioned proper.Sy IOr ins � r 6ses. - - - -SEE REVERSE FOR EXPIANATORY LANGUAGE � � � � -� � � � � �� � � --� � �� /� �� nature Permitteo a�e � ` �.. .. .... .. . � ,J. . �.__.__J 1, --- -� - -'--.—_—� _-^-- � � �'� � I I I i I-''�` I � i ' ( r C� (`, �� '� • � � � � i i 1 ' I i ���.���4 . C' i � c I� ' I,�' � i.' �•�'� � I �am.4 zs� 1 !/ �1 � '�' � I I f`� I_ i t I � �.. ,• :� '�. ,` I� ' : I �' i I: I� �`' I r,t+"� �: • ../ y} .' I ,i r i i i I f.' �i.I I I • ' +]"�>�t C O � + I _ '• � .� _. � I _ ;' �. i ''�i� ���.Y. J� I' i � ( �.� � '� I. I I/ � � . .+ 1 ' ! ' I I ''1 . �' , ' ' ��1 ~ ' ' '_ _-_ _' ' 1 ' i i . . `' � e �a"�• � , , . , , y`.'. . I J � � I ��„ � ' �� • e�"."_ �, � � ' � � � �� ,��-. � ! 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