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1323A (7)
WOHKERS'C:OMt'ENSAIIONDECLARATION 76A6E3 �o�s� {�.nn, p^A9".1l1P1 Cf1rf CI CP+'T�1l�A1 �1']G�I►AIT � � I hereby af�rm Ihat 1 ia _ a� ar!i(�at,of consent to self insure, ce-sosG ji�.�-L/VHI-IVIY-f-Vfl-GI..Cls�l-C716,rf1L=-�-GRtViI i "} � . � or a oertrieae of Work ripei lion�nsurance,or e certiti�d COUNTY OF LOS ANGELES BUILDING AN6 SAFETY LJ } copy thereot(Sec.380GLab.C) i � 'r'uilCy N0. _COI'.1P311y �CR APVLICANT TC FILL IN .i08 � � � ❑ --- --------____ nooaes; p� � '�- . j Certitied copy is hereby fumished. N�w Residenlial Bldgs&Pools EACH NO. FEE , � � 1&2-f-amil S ,FL � — $ LOCALITY . i Certitied copy is flled-with the county building inspection y q tlBpBl't1110!1t. MUItI-f2fllily Sq.�t. — NEAREST /'"?_,_ ' �' °� . I'--- CPOSS ST ��'ld RcsideMial Swimming Pools OwuER OR � Date Apolicant �� i �I� FIRM NAME (,{' y I � CEHTIFIGATE Of-.GXEMPTI�N F-ROM WORKGRS: � I MAi� �+ � COMPE�ISATIONJNSURANGE� Outlets.Rec—Li nt—Sw.— qUOFESS ,�� �ry (This section need not be comple4ed if the wdrk involved by the First 20 �- � Total No. Additional � CITY Tel.No. - permit is ior one hun@red dollacs($700)or less.) I i pLAN CHECK � I certity that in the perio��mancaof�the worl<for whicM1 this permit � APPUCnNT � is issucd,I shail nor cmploy any person in any manncr so as to — becor,�e suoJect!o the Workers Compansation Laws. � � Lightiny Fixtures First 20 � AODRESS • -- �i �y � Additional _ - /���,�..,/ Total No. C1TY TeL No,�,�.,.. � L�p7ate� �' -. ,Applicant J ,�^ L.i�lUt<- Fixed A lia ices Not Over 1 HP /7 E /�: F�P'� PERlAIT � � JOTiGE TC. �iPPCti;AivT' '1, a9'tar rrak�ng ihi� Certificete of I APPUGnNT 1+. 4.4'�,.' ; Exemption,you should be�ome suhject to Yne Workers'Compensation Range— Heater_ D.W. _ . � provi5ior�.5 of th2 Labor Oode,ynu musl fortt�with rnmply with suCh Oven — Dryer_ W.M.__ - ADDRESS y provisiorw or this permit snatl be dcemcd re�rolwd. - Top _ FAO _ W.H._ � � � LIC6NSEC COh?I-,NCTO�S CECLARAT±ON- — I CITY � ��/�����y Tel.No. Hood— Fan _. Cther____ i nereby affi,m that 7 am I�c nsad u�de�pwwsions of Chapier 9 uGENSE OR ,�" -,commencme witn Seciwn FUti�Ji cf Dmtsion 3�of the$usiness and Disp. __ lioom Air Cond. I REG.NUMBER ' � - ��a"- � Pre`esslons�ode,an�nry,icense is in fu�l for�e and effect �, �iSrr�ir,r No- PZOCESSED BV . Power Aopzrrtus& arge ApUliznces �� � � Size&Tyn2 HP,KW,KVA,or KVAR � � License Number___._ ________..__Lia Class__.....__.._._.____. Up to 1 IneL FINAL U � Over 1 lo t0lncl. -DATF VAIi�AT10N g C;o�tractor Uate______—.____ Over 10 fo SO Ind. � ❑ I�m exempt imder Sec. Over 50 to 100 Inc. i BYAL � � � Over 100 � __ 'n- ,� L3X,P.C.for this reason �r-- -� � Sen�ices,Swbd.,MCC 8 Panelboards I . � � — —Date:----- 0-20�AmP.Under 600 V � -- Siynature ^<O1-'L`00 Amp.Under 60D V i I � -Over i0(�U Amp.or Over 600 V � ' Exemption for Reg.PAaint.Elect. ' � SiNGLE FAMILY Temp.Power Pule 3 AU�urlenances � ! , H0�,4G OV'JNGR-BUILDGR D[GLARATION -gign with OneBrancn Circuit 8 I hereby affinn that I am e>:empi from the Contractor's t�icense Law - � for the foilowing reason(Sectian 7031,5,$usiness and Professions Nddltinnai Sign Branch Circuits _ . �t Code;: - �� ���.i:�P�: � � - -Misc.Conduits 8 Conductors — � s" I,as owner o[tl e properly,will do the work and the structure .�`F� � � m�°� is not intended or of;ered tor sale(SecYion 7044.Business Other(See Complete Eee Schadule) I -� � anU Professions Codel. � �t * m.s,(`j�u��(f . � } CONSIT,UCTION LE�JDING AGENCY �a a ��r`�;��� � I hereoy atfirm that there is a construction Iending aE7ency for thc � � performance o�the work for vohfch this permit is issued(Sec.3097, pERMIT FEG (Sub-Totaq yr� v 7 C<-'Z�� f Civ.C.). - � PLM CHECKING FEE t Lender's Namc _ t PERMIT ISSUING FEE �{� �� . Lender's Ad�iress " � � I cerlily Ihat have read ihis applcation a^rd staie that the above �� TOTAL FEE �-�� � intormation is correct I agree to comply with all County ordinances and Stafe lews rcgulatinc� Electrical wi�ing, and hereby aufhorize representativ s o�lhiy County to enter upon the above-mentioned iproperty f spectior�purpo SEE REVERSE-FOR EXPLANATORY LANGUAGE _. � �/�� ; �. j iS�g�ature of Permittee Dat i �C . � � t � {{ ; { � � � 3 � f � � ' .. � .. _ ..._ � .. - � ` �. 7 ' �... € .M:.�.T ] I � � � � : � � } i i � ' � ",i � d ' t I I �uw��� 337t f � ! I � i � ( � i . :� € G .. � € � 3 � � i � � � 4 ! _ i�;�. ; � � i j � � i � � � d` : � ' �y � � ! e � i ' � � . � � � , � ' �! �� 1 .� � � � � i � �-�_ ( ' �r+ F � � � t 1 � � � � � � � ��+ _ � , � � j ' � � � � � � .� � , . _ I E�,,'��# ������:,f # j ? � ' � I � ` , ` : , � I � j ' � i � j � ; � v ' ` �: �m � � � � �.� � � A� � � � � � , � � i € � i � t �' �,.�'c� I � �'i � . � � � � ( � € € � � . r .r�,._. {S�." ! 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