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:��, � �NORKERS C'OMPFNSATION DECLARATION � 7nana3 toiat /� p�' ��/�T ^�, -Gnp C! �('T�DI�'A 1 p ��`/�T 's ! h=•sby nffirm •he• �c.e - ��•�if'co': :;'consen�ro sei� ' �F-pA`r; t'!�a vi:r.�L'9� : vi: irrv a i�lisi�i i-�16i1�\i 1 � � ir�sure,or a certificute of Workers'Compensmion I�surance, COUNTY OF LOS ANGELES @UILDING AND SAFETY nr a certifiea copy thereoF(Sec 380Q Lab.C.) � P�olity No.__�_ CornpanY__ FOR APPLICANT TO FILL IN J06 `��r�GI 1 j (,/�� Certified mpy�s hereby fumished EACH NO. FEE �+DDRES.S��(� b� C..7 New Residential Bldgs.&Poois ❑ � g _ S LOCALITY ��„ � Certlfied copy�s filed wilh the county building inspec- . i&2-family,Sq.Ft. — r�.�L.1,� -tion depanment. Multi-family Sq.R. NEAREST � G�� CROSS ST. ��(,_ � Resideniial Swlmming Poofs OWNER OR Dole___. Applicant FIRM NAME � /C: � CERiIFlCATE OF EX[MPTION FROM WORKERS ' MAIt � OuHats:Rec�Light�Sw._ 4- COMPENSATION IN5URANCE Firsi 20 �nDoaE55 jJ/�� � - (This ascfioa need aof be completed iF 1he work involved by Tmal No._� Additional � CITY TeL No. � ih¢permit is-for one hundred dollnrs(5700)or iess.) � PiAN CHECK I certify that in�he performance of tfie work for which ihis - APPtICANT permit is issued,I sholl not employ any person in any manner � so as to b om subjed to the Workeri Compensation laws. - lighting Fix�ures First 20 ADDRESS yJ Totai No. Additional Dates���r ApplicaN � CITY TeL No. NOT�C TO PPUCANT: If, af'er making ihis Certificate of F�xed Applionces Not Over 1 NP pEenn�i Exemption, you should become s�6ject ro the Workers' Range_Heater_D.W:_ APP�ICAM Compensation provisions of ihe Labor Code,you musr torth- Oven _Dryer _W.M.� ADDRE55 �: with comply with such provisions or this permif sholl be Top _FAU —W.H.— �_ de2med revoked. CITY � � Tel.No. LICENSED C6NTRACTORS DECIARATION Hood _Fan _Other_ �' D+sp. —Room Air Cond. � � LICENSE OR �_ Class. I hereby affirm ihat I am licensed under provisions of Chopier 9 REG.NUMBER (commencing wiih Section 700p)of Division 3 of-ihe Business CISTRICI N0. P � E$$EI}'BY �� �_- and P�otessions Code,and my license is in full force and effect. Power ApparatUs&Large Appliances � , � � Size 8 Type HP,KW,KVA,or KVAR _�,.�,.r�v'y�--�� (,2 -. iicense Number Lic.Class Up to 7 Ind. FINAL L� y � Over i to 10lncl. DATE ��� yALIDATION � '�-Controctor_ Dafe Over 10 to 50 IncL PINAL � �' � ��:❑ I am exempt under Sec. Over 50 to i0p I�c, BY Q,' �� �'�.. - 8.8P.C.for this reason Over 100 _:g C �G i E�� � �. Services;Swbd.,MCC 8 Panelboards � -- � _ _--Oate: t7-200 Amp.Under 600 V � � �� e� -. . Signat�re V_____ ..�_ 2Qi -1000 Amp.Under 600 V �y $ �,� �_;:1 r . ; ;�OQver 1000 Amp.or Over 60p V . � _ Ezemption for Reg.Moint.�lect ( ���j � E �2 h � SINGLE FAMILY Temp. Power Pole 6 i�pp�rtenances . - �`� OMF OWNER-Bl11tDER�ECLARATION -Sig�with One Branch Circuit � . � - I hereby firm ihat I am exempt from the Camranar's License qdditfonal Si n Bionch Circ�its Law f the foliowing reason (Sadion 70315, B�siness and 9 � � � rof sians Code): � � . Misc Conduirs 8 Conductors � . I,as owner of the properfy, w"II do the work and ihe Other(See Complete Fee Schedvle)_ � strudure is nm Intended or offered for sale (Sedion �► � 7044,Bus ness and Professions Code). � � CONSTRUCTION LENDiNG AGENCY � � � I hereby affirm that there is a constr�dion lending agency tor � _ � � � � - the perfiormance of ihe work for which 1'nis permit is issued PERMIT FEE (Sub-Total) %��-' � - � - � � (Sec.3097,Civ.C.). - - PLAN CHECKING FEE � � - Lander's Name � PERMIT ISSUING FEE :``�+`-�` `�'� � . - � � Lender's Address ^�� - � - � _ I cer?ify thot I have read this applicotion�nd state ihot the TOTAI FEE s_a���"�` � a6�ve iniormation is correct.I agree to mmply with oll Counry . . . � ordinances and Stafe laws regulating Electrical wiring, and � � � � � � hereby aufhorize representatives of ihis CouMy o en r upon , . � � -mer�ioned properry for inspedion/ r�� SEE REVE&SE POR EXPLANATORY LANGUAGE {{ �� ?. i naluree P rmittee �� �a,e - 1 ! � ' � � � � _ � � i < E ! 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