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WORKERS'CO".'.PENSA710Y DECLARATION �t�,�,3 �o�e� ppp��CA710N FOR CTRICAL PERMIT �
I here6y a(firm thoi I hnvr. o cer�ilicote oi con�ent to se�f CE B�W
ins��n,o�a cerrHicoie of wo�kc.i Compensaron��su�a�ce, COUNTY QP LOS ANGELES BUILDING AND SAFETY
or a cer"lied copy�herr.af(Sec.7800,tab.C.l
a�y� � COmpOny_�` FOR APPLICANT TO Flll IN !OB ,p __
Certif�ed copy is hereby(�rnishad. New Residr.niial Bldgs.8 Pools EACH NO. FEE A��E55 1 [4i /G COV2
�erli(ied copy is filed with th county bu�l g insp c- �R Z�Family,Sq.FI. S = S �CCALITY X�
han d«oarim nt. � ��,, Multi•(om�ly Sq.Ft. NenkEST
CRO55 ST. v •W� �
Residenliol Swimming Pnnls OwNER OR
D�fe � Appl�cant
FIRM NAMC ,j
CERTIFICATE OF EXEMPTI N FROM WORKERS' MA'L
COMPENSAT:ON INSURANGE Ou��e�s:Rec_l�gh�_Sw._ ACDRF55 � s3a
(Thia��clfon nNd not b�complefad if�hr work inrolv�d 6y F�rsr 20
fha pormll it for ene hundr�d dollnrs(SI00)or I�ss.) Toiol No. Add�fional CITY Tel.No �'r a
P�AN CHECK
I ceriffy�h�t in the parforrionce of ihe work for wh�ch it�is qw�iCnNt
pr.rmi�is issued,I shall not employ any pxrson in any monner
so os to become subjecl to iFe Workers'Cempensa!ion Laws. ��ghiinq Fix�ures Firsl 20 ADDR�S$
Tc!cl No. nddl�ienal
CITY Tel.No.
Do�e Apolicant Fi.ed Applfonces Not Over 1 HP pFp,y�p
fVOTICE TO APPIICANi; If, nf�er moktng �h�s Certifica�e of ����A^T G
EMemplion, you should bacome subjec� �o �he Workeri Range_Hea�er_D.W._
� Compens�iion prov�sions of rhe tobe•Code,you must forh- Oven _�ryrr _YJ.M._ ADDRE55 ��
w��h tomply with such provisinns or ihis permi� shnll be Top _.fAU _W.ki,—
deemed rPvoked. � Hocd _Fon _Ofher_ CITY � L nl. o.�jsl�+�
LICENSED CONTRACTORS DECLA4ATION LICENSE OR
I hereby o!firm ihoi I om licensed under provisicns of CF�o'er 9 Disr. _.{oom Air Cand. — RFf,.NUMBER Class. � O
(commencing wi!h Sect�en 7IX!0)of Division 3 of the Business power Ap aro!us 8 la�ge An I ances DISTRICT NO. PROCESS�D BY
o�d 7rofessions Cede,nnd my licensc is in full force ond effec�. F P' , ���� �
Sir�8 Ty(�e H?,KW,KVA,or KVAR O C.
License Numbe�_��(Z��Lic.Cless� Up fo 1 Incl. FINAL � O
Conira � 'r(¢Dnte&C.�3•r �� Ov=r I to 101nc1. DATE� ,� p1 VAIIDATION 0
' Ovr.r 10 b_0 IncL FINAL " ~
❑ I am exemp�ur.dcr Sec Ovr,r 50!0 100 Inc. BY w
B.BP.C.for ihis rcason Ovcr 100 a
�
Services,Swb�.,M,CC 8 Panel600rds ► � ?
Dn!e: 0-700 Amp.Under G00 V
Signo�urr, 201-1000 Amp,Und�r 600 V �
❑ O�nr 1000 Amp.o�Ovc�600 V
ERrmp�ion For Re9.Moint.Elrcl. ���,� ��,��O r1
SIh:GLE FAMILy Temp.Po•Ncr Pole 8 Ap�,�erio.�ut�.�z� � I '
FiOME OWNE4�9UILCER DEClA4AlION 5�qn w��h O�e Bronch C�rc��� {;' ,
I I+ereb y af!irm 7!�et I am e:em r!frer�tti>C onnnrt�r's t�c r n s r. AJJiiionn l Si�n 9ranch Circui�s ' • o ` �
Law fo�if,e{ollowing reoson(Seuion 7031.5,Bus�ness ond � ^ •��,j�
PlOIPSSi0�5 CCdP,�:
� Mise Condules R Condueic�s • • •�;�;(1�•
I,os owner of th=prep^rty,wiil c!o�he work nnd the .
str�c�ur�is noi iniended or olfnred fer sole �Sec��on O�he.r(Ser.Compleie Fe�Sche.d�le)_ 0 Ci 1 %—$�
704d,8usiness nnd Professions Code�.
CO!JSTRUCTION LFNDING AGENCY
I hereby affirm th�l ihere is a cons�rucGon lending aqnncy for
ihe periormance ol�he work fer which this permit is itsue<1 pEqMIT FEE (Sub-Totol)
(Sec.3097.Civ.C.).
PLAN CNiCKING FEE
Lendcr's Nome
, PERM.IT ISSUING FEE �
Londer's Address
I cenify�hai I hove reod Ihis opplicalion ond s!n�e�ha�ihe TOTAL FEE
oho�r.inFo�m���on is co�rr.ct.I agrce�o comply wi'h oll Coun!y
ordinonces and Siain Inws regula�ing Eleclrical wiring,ond
hereby au+hor'ze rr,preseN�efves eF�hls CovNy to en�er upon
th.e above .nti �op�ny for insr.eciion purposas. SEE REVERSE FOR E%PLANATORY IANGUAGE
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