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WDRKERS'COMPENSATION DECLARATION 7M663 IOi81 �pp11eqTION FOR ELECTRiCA1 PERM /�/
I here6y affirm thor I ha�e a cerUficate of consen�fo self �E"�� ��J _
in:�re,or o certificote of Workers'Compensa��on Insurance, ��V�{TY OF LOS ANGELES BUILDING AND SAFETY�I T�
or o ceriifi d copy thereof(Sec.3800,Lab.C.) '�+
P�olicy No`�.,/��'�'�3Company'N�S7n1� FOR APPLI[ANT TO iltt IN qppRE55 � S. P_
Certified copy is hereby furnished. /N� New Residentiol Bldgs.&P o EACH NO. FEE
� Cenified copy is 4iled with the county boildiag inspec- 1 8 2-Family,Sq.F�. f — E IOCALITY a / 3�
eporl ent. �/J Multi-family Sq.Ft. — NEaRESt D
/�'��11 Res�deMio4 Swimming Pools OW ER OR
Date �AppIF[on '�— `� ., FIRM NAAAE
CERTIPIG4IE OF EXEMPTION FROM WORKERS' Outleh:Ret_Li9h1_Sw._ ���
COMPENSATION INSURANCE ADDRESS • JC ��a
This wclion nwd ao16�eom I�Nd iF fh�work Invotrvd b First 20 ,
( P Y Total No. Additiana! �TY vr,�a- 9/7��, Te�.Na. 7—ry�S ��.
►ho permlf i�fer o�ro kuadrod ddlen(f100)or ian.) '�
I certif tha�in the 4ormance of t6a work ior which this PIAN CHECK 1
y pe� APPLICANT I
permit is iswed,I ahall no�empby ony person in ony monner
so as to become subjecl to the Workers'Companm�ion lows. Lighting Fixtures First 20 AOORE55
Additional
Total No. CITY Tel.No.
Date opplicant Fixed Appliances Not Over 1 NP pE�7 � ��
E IOTICE TO APPUCANT: If, after moking this Ce��ifimte of qpp���T `��C ._'��,7
. ■emption, you should become subject io the Workers Range_Heater_D.W._
Compenmtiaa provisfons of�he tabor Code,you musf forth- Oven _Dryer ._W.M.— ADDRESS .�_ ��x �/d
with comply witb svch pravisions or ihis permir shatl be Top —FAU -_W.H.— �
deemed.evoked. CITY�� �� /7(��Tel.Nos �
Hood _Fan _Other_
UCENSED CONTRACTORS DECIARATION UCENSE OR p
I hereby oHirm fha�!om licensed under pravisians of Chapler 9 �isp. ..._ Room Afr Cond. — REG.nIUMeEft lJ�3 ��O �� �
(wmmencing with Seclion 7000)of Division 3 of the 8usiness DISTRICT NO. PROCESSED BY a �
Power Apparatus&Lorge Appliances
ond Professions Code,and my license is in full force and effact � �
/�/+.� „p� r`U Size 8 Type HP,KW,KVA,or KVAR � h V
License Number t�lF'�ld�S Lic.Class 4- Up to 1 Incl. FINAL � �
Conirocior�" T-Tl��U/� Date �� �er 1 to 101nc1. DATE 7�3�.�y VALIDATION O �
� 0
� Over 10 to 50 inrl. FINAL W �
I om eaemp�under Sec. Over 50 to 100 Inc BY � f
6.8P.C.for 1hi5�eoson Over 10p z =
Da�e: Services,Swbd.,MCC 8 Panel6oards �
0-200 Amp.Under 600 Y
Signotura 201-1000 Amp.Under 600 V ` � !�''��,
OOver i p00 AmP.o�Over 600 Y �: • • • s c`
Exemption for Reg.MainL Elecf.
StNGLE iAMIIY Temp.Power Pole 8 Apporrenonces � ° `4�� �r-
. HOME OWNER-BUIIDER DECLARATION . $ign with One Brarrch Cirtult _
� �ereby affitm thof I am eaempt from the Confroctar's License qddi�ionol Sign Branch Circ�its i � " � �- "�
�ow for the following reason(Section 7031.5, Business ond ` , .
Professians Code)� CI�.c�`�t:C �
❑ I,as owner of the o r�, wili do the work and the Misc.Conduits 8 ConduUors
P� � Y Other(See Complete Fae Schedule)_ �
siructure iz not intended or of{ered fw sale(Sedion •
7041,8usiness and Professions Code�. �
CONSTRUCTION LENDING AGENCY �
I hereby affirm ihot ihere is o construcrian lending ogency tor
the performance of ihe work for which this permil is issued pERM1T FEE (Sub-Toral) i
(Sec.3097,Civ.C.). R
PIAN CHEGKING FEE �
lender's Name
PERMIT ISSU�NG FEE O
Lender's Address
I certify thm I have reod�his appfication and state�hat ihe TOTAL FEE �� �
above information is correc�.t agree io comply with all Co�nty
ordinances and State laws regvlaling Elecrricol wi(�ng, ond
hereby authorize reprasentatives of thit County to eNer upon
the ob e-mentionad properly for inspection es. �
-�^�,� ���� SEE REVERSE FOR EXPLANA70RY LANGUAGE
Signafure of Vermitte�,/' Daie
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