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f ., ._ m,bci� G ,,,///'''��� # ' WORKERS COMPENSATIONDCCLARATION - 7sA6�3 70/87 �D�I�IC�L�TfC}N.��� �`���-����_�,���MIT _ �.+o.� ° I hercby��affirm that I have a-certificate of consent to self insure,��� � - - -� - -- -� � #�- � -� -�- " -� � - a� ur a ce �ficate of Workers>Cumuensation�nsurance,or a cortified L4l1N7Y-0F LOS�NGELES r� a� �B�IILDfN�ILN��`A��TI�t � �� �opY thereof l9ea.3800,Lab.C.) � . _ - - - . �t 3�,#�'�'s-� � � y. � � ae�ur�e�5 �U"�..� �. ""I�y No. Compsr� FOR APPLICANT T6�FlCL 7N � ����� 7 c'�{<<� �.{{, .m, � py,p ❑ Gertlfietl copy is hereby furnished. � . New Residenhal Bldge.&Fbols EAGH NO.�FEE � � ;4 ��`'Certifed copy is'filed�veith the counry building inspection� 1&2 Famity,SU�F��— �'`� � '�— $ LOGAUTY �-(. ��t{��-y-�p�ti�,1j�,,,j�. e �❑ �-department � � � -� � � MWti-Famil S Ft. — NkAREST � v•4. caoss si �r:tl�.�='{zr�-i4-�..:� j � �- � �- Nes�tlential Svnmminy Pools pWNER Ot� Date AppliCant � FiaM NnME ��'1`� �'`�l �"'t���j� { _�T. -��•CERT3FICAiE�DF�EXEMPT�ON FROM�WORKERS'�: �j� ��,��L € _ Ouilets.Rec�Light_�_Sw.� �qDOAESS 7'�"ta t-. 4tit �.:t-"4>nTY+'Y i�+�- -' �� � COMPENSATION�WSUflANCE � �� •� *'" � � � � F�sst 20 � �.�� �(Thissection need.not 6e completed if the work invoived by the. GITY {_,;,}�r�y1,}Ci'(" Tel.No.� °f I Total No. Adtlitiaiai -permit is for.one hundred dollars.($100)or less.) - — - - PLr:td GNEGK -.I Gertify that�in the-pefioimanCe of.,thr3 Work'fof.whiCh.thi3 permif APPLICANT ° =is iesued,I shall not-employ any;persorrlq-any�manner..so as Yo �� ' �� become sub�ecf taU�e VVorkers'Comoensa�ion Laves. I_ighting Fixtures Pirst 20 �ADDRESS- -� � , � Additional � - Tuta(No.,�_ CI Y Tel.No. �ate Appficant - �- -� �� Fixetl Appllances Not Over 1 HP ,ERMir NOTiCE TO AFP 1 ANT !f, ,lf-� m k+ny. hts l.e:;i ctd�� ��f � I ,pp,- 'p,�T � � � ��Exemptron,you sho�ld,become suhlEct to the Worker�Gom�ensatio�i �-. 1j ��n9e.—Heatr.r_�W. ___ ! � � .provlstor,s of N�e Labor Code,you m sf forthwith comply with auch -. I Oven_ Dryer� W M._ I ' � � A�DRESS .provisions or:hls(.er ni-sh�l.�e de..rrwd�evek_.tl lop _ FAU _ W.H � � � qTY �� �I.Na. +��^. IICENSF��ONTIRAGrORSDE�LARATION� � Hood_ Fan � Olher___ j -� I�,EN¢E OR I herabl atf�rm that I�am�i en;ed umJer provisiens oi Chapter B - Dis _Room Av Cond � � Ciass. C P� — fiEG.NUMBER _ � (commencing w[th Section 7000)of�ivlsloq 3 oi,the Business and . OISTPKT NQ SEO AY � Prafossions Codz,and my iicznse fs in full force and efiect po��Ap�ar4tus 8-LarSe Rppliances � � . Size R Type�HP,KVJ,KVA,or KVAR _ ��'Q"''' • - � License Number Lia Class __lJp to 1 Ind. I I ,� paT�L �`,�y���� � Over 1 to t01�id. _ � VAIIDATION d Contractor - Oate -- i^ � O Ovcr(0 to 50 Incf. - -�FINAL t„) 1 am exemp?under Sec. Ovsr 5a ic 100 Inc 6V 1i" � O�aer 1U0 ( ` triL.A._..�...-�� fl. � . B.&P.G#or this'eason _ � � Servlces,Swbd,MCC&Panetboards ��' I � � k �_. Date:—.._ 0-200 Amp,Under 600 V � �� ��{i t`�.� rn � � 1 Signature— 201-'.^,00 Pme.JnUer 600 V � #! s �,� ¢ .�� g ❑ ��va+100G A�p or Ov�r GOC�J i � �� � Gxcmption for Reg.Maint.tiect. ��w n � r�i^, ,. I S1M�LE FA(�dILY Temp.Fower�efe&Appurtenances �I ,� e � v -'��.�.:. � 'HOME OWNER-BUILDER DEC�ARAYION - Sigia v�th One Sranch CircuiY � � S (hereby affirm thaf I am exenipl from the Contracfor's Lioenae Law���. qddi[ional Sign Branch Circaits (��y}y,�?w{2,Q-"� � for the follawing reason(Section 7G31�,6usiness and Protessions : -� Gotl2i � Misc.Conduits&Conductors I as own�r o°the property.will d�the work antl the slruciure " is nut intended nr offared(or sale(Secfion 7044.Bisiness, �her f5ee Complete Fee SchedWel_ � and Professions Code). —. � - �. _ . � ,��_ __ _� . _. � CONSTRUCTION LENOING AGENCY �� � - j I heraby affirm that therc is a conairuction lending 2gencV fo Uie � - _ - 1 performance of the work for�vhicl�this permit is issued(Sea 3097, �pERMIT fEE (Sub-Total) � c��.�.�. '� . - PLANCHcCKINiaFEE� � . ���- � Lender's Name - �� � � . PERMIT ISSUING FEE � � �� LP.nAer'S ArJdress � ��' � 1 certit�tha:1 have.read this applicaticn 3nd state that the aho�e'- T�TqI FEE .. . .. . __,.:. information is correci.I agree to comply with all County ordinaness _ ' and State iaws reaWatinn. Electrical wiring, antl her2hy authorize��-- . . _. �.. � � r res�e(atives of this County io enter upon thc above•menironed I (�roperty Sor ins�n posea SEE�REVfRSE FPR EXPIANATORV LANGUAGE � - - -�-� i 1�C �? cy� -3�2�- �3`� � Si �ture of Permittee Date _ � ., . � . . _ �...,,.a, .?..H �..,-�.aA,.'G; , �.. _ ... . u ,n._!_,.... a`' � � I i E � .� � € . . .. ., . <,....,, ,r...� � � � " ` � � j i j i � � � � � � � , � , . .. _ . , � � � , , � � � ; € E � � � p � � � i 1 � ; - ; � � � , . � Ij � � � i � j ! ' ; ( � � ii � i � � j I j � ; � ` I � ¢ ` � i i: 3 � � � � 4 , � � � i � ( ! � � � � � i ' � � j � a � � � --i l: I ��r � , � � � � � > �]]] � , � � � � ; � } �� _ �, � _ � � � � I f � ( � � � � ��'��.._�y__a:..'d � . 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