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� WORKERS'�COMPENSATION DECLARATION �� 7ent63 �Oiei:���- � � � �` � � - . ,. _,._. .. . �. I here6y affirm fhat I have a rertifimte of conseni to self �E_�� A�PPLI�ATION F�R���ELECT�tICAL P�ERMIt�-��� �,� , insure,�or a certifimte of Workers'Campensaiion Insurance, COUNYY OF LOS ANGELE$ � BUILDING AND$AFETY��� ������ � � � or o certified mpy thereof(Sec.3800,Lab.C.) � . .. .: . . . .. . . .. . .. . ., :...... : . .�:,....�- . _ . �. . PQolicy No.CI 9�0212�'ompany TT�`A.:�� . . . .. . FOR APPLICANf TO PlLL IN � JOB� . Certified mpy is here6y f�rnished New ResideMial Bldgs.&Pools EACH NO. FEE ADDRE55 Lot. — 2077 Lake Can on � ' - $ — $ �oCaUTv TR #35742-3005 Diamond Ba �Cer7ified�copy is filed wilh the couNy building inspec- 1&2-Fomily,Sq.Ft.�n�34 . - :�� fion deparfinenf. Multi-family Sq.Ft. - NEAREST , , � -Dq1e 8�8 a3 �� ��� ° �� � � Residenfial.5wimming Pools CROS557 / Appl�canr C McGee�7Qrtric OWNEROR � ���� - FIRMNA,1rtEMwJ,. Brqck_& SOriS � � CERTIFICATE�OF EXEMPi'ION'PROM WORKERS'��� �� � ' I mqR - � � Outlets:Rec�Light�5w._ � .� COMPENSATIOPf INSURANCE-` � First 20 � � .� AooRE55 1698 Greenbriar Lri. � #224 (This secTion need noT�be completed if fha work involved by Tofol No. 4 ' CITY � Te�.No. �. The permif is for one hundred dollars{SI00)or Iess.J Additionol � _ � PIAN CHECK ........ .............. .... ... .... .... . � I ce�rlify ihoi in the performance of ihe work for�which ihis . qPPLICANT . permit is issued,1 shall not employ any person in any monner �� � so as to become subject to fhe Workers'Compensatian Laws. �igMing Fiztures Pirst 20 A�DRESS � �� � ��� -� � �- - � � Total No. 1 Additional . Date qpplcani �� -� CITY TeI.Na. '�. � A40TICE�TO���APPiICANP If, after mak ng rh�s Certifimte�of Fized Appliances Not Over 1 HP PERMIT � � �"���'nption, you should 6ecome sub�ect ?o the Workers� Range_Healer_�.W. _ Fl.PPL�CANT C .M G � .npensa�ion provisions of fhe Labor Code,you�must forth- . Oven _Dryer W.M._ ADDRE55,23�0--5.-ReserVoir � . with wmply with such provisions or this perm t shall be Top _FAU 1 W.H.— � deemed revoked. . � - CITY � POICtOrid � � � Tel.No.627—OjjFj� � � �' LICENSED-CONTRACTORS DECLARATION ` �� Hood _Fon _Other_ Disp. _Room Air Cond. — 3 -S ��CENSE OR � Class. ; I hereby affirm ihot-I am licensed under provisions of Chapter 9 � REG.NUMBER� rJ33�]$ .(J—],Q. (mmmencing with Seciio 7000)of D wsion 3.of ihe 8u5iness po,A,er Apparotus 8 Lprge Appliances. DISTRICT NO. n � PRO SSED BY- � and Professions Cade,and my license s n full force and effect. „/ � - � �-. � � � � . �. . Size 8 Type HP,KW,KVA,or KVAR� �� o �Li<ense Number �.53378 � Lic Class :��'—��1� Up to 1 Ind. FlNAL V Controdor� E12C'tY'1C3�.� pa�� �$�$�$3� .. Over 1 to 101nd. DATE � 6j^ �? VALIDATION � � ❑ _ . .. ........ . . .... ... ... -.._ . ... ..... . . Over 70 to 50 Incl. " � !— FINAL I am exempl under Sec. Over 50 to 100 Inc. BV ii � . B.&P.0 for this reoson � - Over 100 � N � - - . � � . .... �. Services,Swbd.,MCC 8 Panelboar,ds ► � Z . .... �� Date' .. ...:." �� 0-200 Amp.Under 6D0 V � � - Signature � � � 201 -�1D00 Amp.Under 600 V .. . . .. ... . .. ... . ., .. ❑ � � �� � � � � ' - Over 1000 Amp.or Over 600 V � Exemption for Reg.Maint.Elect. . � - � � SINGLE FAMILY �������� � ���� -, Temp.Power Pole 8 Appurtenances - . � HOME OWNER BUILDER DECLARATION � Sign vi�ih One Branch Circuit � � F°'�ereby affirm ihat(am ezempt�f�om the Coniroctor's Lmense Additionol Sign Bronch Circuits .v for the following reason(Section 7031.5, Business and , Pro4essionstode): � ❑ I,as ow er ot ihe p operty,will do ihe work ond the Misa Conduits 8 Conductors � � structure s not inte ded or offered for saie (Secrion Orher(See Complete Fee Sched�leJ_ � . . 7044,Bus�ess and Profesqions Code). ,_ . �. � � CONSTRUCTION LENDING AGENCY' � �� ' � � '� �~'�,~� � � I hereby offirm thai there is o mnstruction lending�ogenry for - , a s�_ � ihe performance of the work for which ihis�permit is issued PERMI7 FEE (Sub-7otp1) � ., (Sec.3097,Civ.C.). . . . , �. , „ ,. . , � - . . . , � � - PIAN CHECKING FEE - �. Lender's Name - � � , � � � - . . � -, - .� . � _. PERMIT ISSUING PEE � ZO S Lender's Address � _,��`,. � I certify ihot I Fiave read Ihis�application�ond s�aie that the TOTAL FEE .�.3��1 < < � '- �� above informotion is correU.I ogree�o comply with oll County . � ordinonces and State laws regulating�Electriml�wiring;ond . � , here 'oufh rize represen•otroes of rhis County to enter upon � � � -- � � � fhe � - ned property for inspection purposes. .. , �,� --_.__ $EE REVERSE FOR EXPLAMATORY LANGUAGE __ . ... _ f?f8/A3 � � ignaWre a Permitree . Date - � � � �� � � � - � � � " � � l „, _�. . ._. � '.AppRC�/ALS . ... . �ATE . ..I . .... . . .. . ..... .... . QW ..- UILDER . .. . . . . -� ” � NER B ' DECCARRTION ,,, �_, �. ., 5!GNATURE � -•�- � �. � i hereby affirm tha'I om exempt from tr.e Contracto✓s - �<: '.��. FEMP POIYER:POLE� - �: _. ..: -.•-. � . �_ � - — �- '� �� � � � License Law for the following reqton �5=cilen 7037�.5, UNDERSLAB WORK � � � - - � � � 8usiness and Professions CodeJ:Anycify or couniy whrcb � --� ROliGH CONDUIi, . � reqqires opermL':fo.consfrucf,c;';er,imprave„demolish. . .. . , ..._'. . � . : -. - - � _ '���-�'�orrepolr any siructure,prior Po its %ssuanae, also re- : . . .. ... ... . WIRING � ��!��� , �P�'"���'L�''� qufres fhe appliaant forsoch permit ta file a srgn=d state . . � �� r- . . . ment that he is llcensed pvrsuaM to the provivons of tl:e , �� � - , � . FIXTUkES � �� �- � _ . .. Con7ractor's Eicen:se Law.(Chap4e�4(commencing with � - � � - -�� POWER AUTHCS�IZED � , Section 7000)of Division 3 of fhe Business and Protes- �, � sions Codej or that he i�exempl 9Ferefrom and ihe bqsis ... .� � � -'�� ��� -�- LJ71LlTY CO.NQTIFlED _, � � . ior the alleged exempt'ron. Any violotion of Sact'ror, � - FINAL . �r , . � �� � � 709LS 6y-ony appHcant for a permit su6jects the appli- -� � � � �- C+�� � �� E � � � cant to p tiuif penaMy of no!more fhan flve bvndred . . .,..... ..� 4....,.._,. ...._.-...,..,_.....,....,:..,,_.,..:.� �.,::....� ..�.,..,,. __. . ,d�..»a,.......:.._..... . . . . . . . . . ....�... � _�. .. _ . NOTES � � � .. . . . c�o1?�ars�($5d6}.: . � , • ❑I,os ewner of!ha property will do}he woric,ord ,... --. . . . :,.,. � . .. . - � � � � � � � � � � tne siruature is noi iNanded or offered for sale. � ' __ - ,,. .,..,,,,,. ...:,,.,........,.,.. ..,�„.,.:<. ,,. ..,M:.�..: ,,,,,...,,r_�,vs.��.,�exm�e..ars�u;�..•,,,s�.v�;.,:,.e�F tSee.7444.�tiusines`sdndPFofessiors�'ode: TheCom. .� _. .__.. : . .. - � -� � -- " � ' �� �-'� � -� �-- �- � � tor's Licanse Law does not apply io on owner of properiy � : . ....�.� . . :.:,.,..,........,..-..,.,.. ..,..... .,-..,.....v, ....:�...,..:..z: ........:.K...�_�.�x.}�=�.r.zr:+.n�'^,.�.:c:�v✓ho bullds or Improvas iberecn, and who�does�such � � � �� - � - � work�himseif provided that such imp�ovements ore not _ �.. '. .. .:. - ,. ..»....,r.. ....., ..:...._., .:.,.,,,.., ._,�..._,;�... ......................._....�m::,....... . . .. .ifianded o�offered�forsale.f?,�how.ver,fbe building or ......... .......... . � . �-�� � � �-� � � � . �� ��� improvemant!s soid within one year of cemplafion,the . � . . -,-. .......-..�N. ° ^`^�.•..:�'.�'••"•"���"'*^'""*�"""'�s'�""°"'" . �ier-liuifdar wil(have'i6e 6urden of proving thoe he did - . .. . .. � . . . � � � � � � � - not hui�d or improve for the.purpose of safe.) . . . ,._.�,,,.:... .b�.,F�,:�.v� ��.«.��,.a.,��.�.x�t.:±x��e;a�.x..u:v,+,�:,w«.-.w.a.:;..s,�F,r. .y�...r�...3,...,,�-r.�..-um�s• .....z . .. .. . .. . .... .......__. ...«.. ,_, � :.,:, � .�,.....;:�:. � .. . . . .. . . ..�.:...._ :�. �. , � �� � ��.�: �� ���� �� .. i am exempt under Sec. � • � - ....................w«.,>.,.<....�,...-,,..�...�,:..�.. .. �ew� --�t�,aaam�.�.�..' ........:..�..:................., � � �_ ,., B&P.C.for this reason _ � � . . ..�. .. _ . . . ... w.:�,...,.��.... -.-..;+v�...s.:=.,,_-.�.vea,m�.u*�,:x:az�,.�c.�z< .,_. .......,..... ....... � . . . . _ .. �� . . .,. ,._ . ........:�.. ..",,.. .. :_.:::�� ,�.,«:.,:. - �+�s��aa�,raax..vx�aeKr�.vM.e„ .+e.r.,.r;.��.µ.. . .. . .. ...... .... .... . .. ..__.....— —_—..... . r � Dcte_— ..... .,.�._.., .. .�..:.....�..;...,..a...�......,.�.:w-..�..,..,.�.�.:,w.,._.w:wv.�a+,w,:_.aaw.�z..,,,.w�:..�ez.rrs. .<�„..,..v, � �.,..,,,.:..s..� .,..�.�,..�.,,.„.. . . . . ;.. ..,.,�...__ ..... .,.�„k....-.«..... .-,.,,��... .......,. �Owner_ __ ..— . ...,,,....... .....,....,,_.,,,.,.,..-,w:,,:,,.Y,..�..,-sre�.w;-,:...�-,.aa�w.n.»a�..w*,.....,.rr ,.�.,:.:: ..�...._�...,,�sewu�:w.u..a.e...to+�..w.�vw�3:d+aaun.a.:.wrrnw•�.c....�...:.r�...�..a��.�..�:...a- . . .... .,.,......:. ...,_......,,.. ... ;�..:..... . .......:�.,.ro�.:,. ...'.....�.... ...✓,au...:oiA.LT....J,.:.-i' rw�Z.�:..:.s,.>�Nm.,n.<6f%.�i,�rvi..n.ie"w�rv:t4:;PlEnwy w....ri�w'¢?'3�,Lf.iuMY4d�4::..�l.l'Jfd'u'�`3� "::... .. . . ... .. .......�w.1.. ..c..;,t•;•y-vr�e-.m+ ...+....•,n..m'i'tiw_t.MY. . _ .,4 . ....�.�..�.. . �y..��iM.taeMiaveo-mm� ss�ww�:. . ... .... ..... � ............._ ww........v..»...nT...n.r�.w.n..Ww.E-�raw�..ic�i+numvHs+#o�::..�� . . .;":' . � 9i3Y9F41L1um6%S.M.1.G:YiR.*W..L•uXYA#^d'+>�m, .•�..:.�.. .'.' . . 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