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WORKERS'COMPENSATION DECLARATION 78nsss t0/et � � � I hereby aifirm that I have a cerlincate ot consent to sell Insure, ce•eoSG APPLICATION FOR ELECTRICAL PERMIT or a certificate of Workers Compensation Insurance,or a certined COUNTY OF LOS ANGELES ' BUILDING AND SAFETY copy thereof(Sec.3800.Lab.CJ - PolicyNoC-�T401�363ComParry��nuST6�1h1 ��� FORAPPLICANTTOFILLIN - - pppqE55 ��V {"} � ❑ CertiFied copy is hereby lurnishetl. ,. New FiesideMial Bldgs.8 Poo s EACH. NO. FEE. l� � . . . , 1&2-Famii �I 3'7 s D — s65' LOCALITY �'S��-V � �/ �Certified cOpy is filed with the�county building inspection Y.SQ.Ft. department. � �� Multi•family Sq.FL — NEnae57 -y�, CRa55 SL .V �Date 3o Applicant Residential Swlmming Pools � � rnvNeq on /� FIRMNAME ��{'1' CERTIFICATE OF EXEMPTION FROM WORKERS' � , Outlets:Rec—L'ght_Sw.— � � _ �� o �l� �- � -.COMPENSATION INSURANCE -��� � nooaeSSJ I S t N�� This saelion need not be compleled H the work InvWved the First 20 _ ��T Tei.No.p permit is for ona hundretl tlollara�$700)or IesaJ � � Total No. � Additional . ���A� CS 26�� os�` U� - PLAN CHECK � I certify Ihat in the Derformance of.the vrork for which this permit - � � �� pppLICADfT - - is issued,1 shall not employ arry person in arry�manner so as to - � _ become suhiect to the Workers'Compensa[ion Lavrs.. , , L'ghting Fxtures Flrs[20 - - - - AODRESS - - �� - Additional � ' ' � � � � - -- Total No. � CI7Y�- ' � � Tel.No. Date APW�2^� �-� ' � - Fxed Appliances Not Over 1 HP peRMir � �r r � NOTICE�TO�APPLICANT: If,-after�•making this.Certificate of A7PUCnwt � FF l= -C �l� Exemption,you should become wblect to the Workers'Compensatbn .- .....Range_Heater_ D.W. _ pro-.isiarr ef t`a Labcr G^.dc��„u rco••o»�:a:h ccmR:�'�•:i!h��h O:bn_CRyer_W M._ . ._. � . . ..- ADDRESS . .� provisions or this permit shall be deemed rewked.,..,. , - - .Top-_FAU _-W.H._.. _ ___ -_ - . .. .. CRYC - d ��Tel.NoS . S/� � . �-� LICENSED CONTRACTORS DECLARATION �,� � Hood—Fan — Other_ I hereby affirm that.l am licensed urWer provisions of Chap[er 9 . -Disp.�--Roan Air COM. - uCENSE oR �-- Class. - � (COmmenCirg wilh$ediorl 7000)Of DNIS�on 3 Of 1hB BuSine55 and — REG.NUMBER D 3 '�-" � �� Pro(essions Code,and my IiCenS9 iS in fUll fOrce and effecl. pm.,e�qppyfaSu9&L3rge Appfiances_ _ . DISTR�C7 NO. PttOCESSEO BY - .. . _ _. .. �.l __. Vy� _j_. ._. } I'p. p /'���� Size 8 Type HP,KW,�KVA,or KVAR V 1' \CL\G n e O License Number ! / ��O 3 Lic.C�ass�iL_ --� � � --�Up to 1 IncL � - - � � � � FlNAL y'yp' - - V �IL'C.rRCCQ�/ Date Y�9 Over 1 to 10lncl. DATE � I SiU/ � .VAUDATION._ � �Conhactor Over 10 to 50 Incl. V� ❑ FINAL I am eacmpt under See. Over 50 to 1DO Inc.- . BY - 88P.C.for Ihis reason ove�ioo �1 1 7.8 A � Services.Swbd.,MCC 8 Panelboards--- �� � ' -- � � ��� Z --- - - � �. . . � .2 - --Date:"� 0-200 Amp.Urder 600 V � Siqnature � 201-1000 Amp:Under 600 V- --�- --- �- - � � � � � ��-� �� � _a _ -- we.i000 nmP.or aer soo v I ^ a 7 5 9�T ExnmpFion 1or Reg.Maint.EleCt. -r,� � .. - "7.��Oo� � � SINGLE FAMILY . ... Temp.Paver Pole&ApWrtenances . __ . . . ' HOME OVJNER-BUILDER DECLARATION si9n with one Brancr+ctrcuit - - 0 a 2 6—8 8 � � I hereby alfirm that I am exempt 1rom the Contractor's License Law Addifanal Sign Branth Citwits - � � for ihe following reason(Section 7031.5,Business and Rofessions -� -- "-�---" -- �---" - �" �� -" � � � " . Codel:' will d0 the work flnd the structum Misc.Condoits&�COnductors -�- - � � � ��� � � � � ❑ I,as owner of the propertY. Other(See Complete Fee Schedule)_ is rro}iMendetl Or offered For sale(SeCtion 7044,Busine55 _ . . . . � _ . _.._. .. . ..._ . and Professions Code). � CONSTRUCTION LENDING AGENCY " � �- �- � - � �� � ' I hereby affirm that there is a construction IeMirg agency for the performance of the work lor which this permit is issued(Sec.3097, pERMR FEE' �� - � � (Sub-Totai) '- �� -�--- -��� -- -�' '�` ' � -� � - � - Civ.GI. � PLANCHECKINGFEE..�.______.._._'__ . ._.. . . _ . ._ ". . .__ . _. . Lender's Name • ._ PERMIT ISSUING FEE -- -- - �-�-� �- - �D O - - - -�- - -- --- Lender's Address I cerlify that I have read this applicafron and sfate that the above - TOTAL FEE . . . ... - . S - - - - - - - � inFormation is correct.I agree to comply with all County ordinances . and Siate Wws regulating Electrical wiring,and hereCy authorize _ _ - , . . ' . . .. ._.. ... _ _. ____ . __ ' representatives of this County to enter upon the above-mentioned . proper y for inspection purpases. ._ . . _. 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