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0666A (4)
' WOj2KER N�ION DECLARATION � 76A563 ,o�e, �i�i rV1C ��.�LL.1 Kl�.fiL ������ 51 � �_ p pr�� �s�w T� u rs+e� s+T.�.■�.__y I nereby.���th �have! erfiflcate of consent to self CE-r30eG A� f L'7�rf'�,f 1 r insu��'o. c t cate of Wq'.k�{rs'Compensatio���surance, COUNTY OP LO$ANGELES BUILDING AND SAFETY }� cer i� py thereof($ec_r 38Cp,Lab.C) . olity o. Cg�oany_ FOR APPII[ANT TO FILL IN , ADDRE$$ .� � �� C .ied opy is aereby fumished � New Residential Bldgs.&Pools EACh' NO.� FE � _ - � �� ��� 1&2-Famil S .H. � — S � LOCALITY °���„�}f'� Cer�ifie y is 4iied with ihe munry build�ing�nsper Y� 9 � � epartment. '�. Multi-family Sq.R. NEARESI �- j ,CROSS ST. �� �'R✓ Date ApplicaN Residentiol Swimming Poois OWNER OR J7 •--�'--' � $ � FIRM NAME C_ - � CERTIFlCATE OF EXEMPTION PROM WORKERS' � i�� Outlets:Rec �ighi_Sw._ � . . : COMPENSATION.INSURANCE ADDRE55 � �7 Thfs sectiomnued not 6e com leted iF ihe work involved b � First 20 -- � P y Totol No.. Additional � CITY �„� Tel.�,p o. � the permif is for one hundred dollors(57001 or kss.� p.q CH I<ertify ihot-in the performonce of the work for which ihi5�. APPLICAN7 permit is issued,�f shall�not employ pny person m pny m�nner: � so-as:to 6ecome sobjed-to the Workers'Compensation Laws.- �lghring Fixtures First 20 ADDRE55 . � Addluonal .... ... .... _ Total Na ClTY Tel.No. Date Applicant Fixed Appliances Not�ver 7 HP I � F�g,y��T ., ,�e,n �/�y y � NOTICE TO APPLICANL �f, p#ter moking tFiis Certificate of � �APPLICAM /'/`fj'�'i1L/�� ��- 1��^° Exempiion, you should become subjeci 10 !he Workers' Range—Heater_D.W.._ � Compensaiion provisions of the Labor Code,you most forih- Oven _Dryer —W.M.— � DDRESS f���� j�yd�,/�% � with comply with such provisions or ihis permit shoil be Top _FAU —W.H:-- ,� Y tj� daemed revoked. i � CITY� � �n�f��}y'r��nJ Tel.No_����- E. Hood _Fan _Other� �' LICENSED CONTRACTORS DECLARATION 'LICENSe OR I hereby affirm fhat I am licensed under provisions of Chapter 9 Disp. —Room Air Cond. -- REG.NUMeER. �' , ,�� Ckrss. �,�.a y� (wmmencing with Sectiqn 7(NJ6)of Division 3 of the 6usiness j DISTRIC7 NO. � PROC BY �-. and,Professions Code,and.my.li:ense�is�in full force and effecL �P�wer Apparahus&Large Appliances �y q J� //�} Size 8 Type HP,KW,KVA,or KVAR � �s�--•r � License Number'� �"���� Lia Class ���-�' _ t1p to 7 IncL p�ATE� �y. O� � Over 1 to 10 Incl. ��-^.��"L�� VNLiDATiON �� Cantrodnr . Date� Over 10 ta 50 Ind. . W" FINAI � y,� �,. � ❑ I am exempf under Sac. Over 50 to 700 Inc� BY �/�*-fv g �� � Over 100 _Q � �. �S B.&P.C.fer this so _ -- ..� •�� . � _ �'- pat� Services,Sw6d.,MCC 8 Ron�rds d,+a-� � �� � �/ � D-200 Amp.Under 600 V /� I'- � Signatur�� � � � ��'g"�"� 207-1000 Amp.Under 6D0 V � � • Over 7000 Amp.ar Over 600 V � ❑ Exemption f r Rey.Moint.EIecL ` � SINGIE FAMILY � ie HOME OWNER�$U�IDER DECLARATION Temp Power Pa &Appurtenances $(}b,('��fj A _Sign with One Bronch Circuif i I hereby afflrm ihot I om exempf from the Gontrac�or's License -�e a �6-i`Z � Low for the following reason(Section 7031.5, Business and Addit onoi$ign Branch Circuiis � Protess�ons Code): . i s,s.CJ��� � ❑ I,os owner of ihe property,will do ihe work and the Misc Conduits 8 Condudors - _ � Other See Com I te Fee Schedulel._ ► s o�e� structure is noi intended or offered for sale (Section ( Pe � �.�U C J�o 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY � �.��'�J 1�:'"�H 8 I hereoy affirm that ihere is a cansiruction lending ogency for � ;�� ihe performance of the work for which ihis permit is issued �..PERMIT FEE (Svb-Total) � (Sec.3097,Civ.C.). � PLAN CHECKING PEE - lender's Nome � - � PERMIT ISSUIN6 PEE Lender's Address_ �.. .-� - I ceriify fihnt I have read ihis applimlion ond sta'e ihat 1h2 iOTAL PEE �� � - . above Informntion is correct.I agree to comply wifh ail County�, - � ordi es and Siate lows regulafing Eleclrical wiring, and- eby ut ize r resentatives of ihis County to enter upon� � - the a m miio ed pro�erty for inspecfion purposes. �, � � SEE REVERSE FOR EXPLANATORY LANGUAGE ;✓`� %9 . �� ��j �-4�- ! �Si noi re ef Permittee Date � . � —"`'#;.-=:: _ ? j � ; ; � t i , ; ; ; ° � ; . t � � , � � � � � �' � � � � I € ` � � � � ` � `` € i ' ; I � � � ; � � � �� � ��� � � � � � � � - ��'� �, ; € , � � � [ � � � � ; � � -j f � � i ' � ' , � , , � � � � , � � � � € � E ) F ( � � (( . . . f � � I j� � �� � y �€ j ( � � E � 1 � � t ' B € g � E ( y 3 g :± � � $ { � € y I � ? { _ � -.� _�. - 1 E B i g k � e � � £ � S � �. ! 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