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�� ` WORKERS'COMPENSATIOW�ECIARATlON GE�-BQ6G��_g� APPLICAT`�.ON ��OR ElECTRICAL PERMiT a( �
�I�ereby aHirm that I have o�certifim�e of mnsent to self _.
msu�e, or a certificate o#Workers'Compensation Insurance, COUNYY OF LOS ANGtIE$ . BUILDING AND SAFETY
oio c�errt�if,piead copy�hereof�Sec.3800,l C.}
V�o'�Icy'F�d O S ' � Compony ►OR APPUCAM TO Fl��IN J09
Certified co y is hereb fumished. EnCH NO. FEE �+�DRE55 �'�.�
p Y New Residential Bldgs.B Pools
� 1 8 2-Fomii FI. f = S LOCALITY D\pI�+.F^�
Cerlified copy is filed with�he couNy bvilding inspeo- Y•�� f2�
tion department. Mul1i-lomily Sq.FL CROSS ST. p ��
Doia ��SLY_A 1lcant 6 Residentiai Swimming Pools OWNER OR Q��
PP FIRM NAME �� `3V�
CERTIFICATE OF EXEMPT N FROM ORKERS' Ootlers:Rec__tight_Sw._ ��� ,
COMPENSATtON INSURANCE ADORE55
Fi�s�2b
(Tlyt soclion naad not bo complafad if Iho work involvQd by Totot No. Additional CIiY ,� Tel.No.7l�(pZ .�
Ih�pannif i�for ona hundrod dollars(;100}or lo�s.)
PIAN C ECK
I cerfify �hai in the perFo/monce of the work fo�which�his _ . - nvPLICANt
permit is �asued,I sholl rtot employ ony perwe in any manner
soas to become subject fo the Workers'Compensation taws. 1i91�ting FixWres firs�20 ADORE55
Totol No. p�������� CITY Tel.No.
Dak opplicant Fixed Appliances Not Over 1 HP �
NOTICE 1'O APPLICANT: If, ofler making this Certificate of �pP�ti�UNi
Exemption, you should become so6ject �o the Wo�kers' Ranqe_Heater D.W.� � - �
_Dryer W.M.— ADARE55 ' �
Compensvtion provisions of the Cobor Code you must forih- Oven _ _ _ _ . .- - - -
with comply �aeitb.such provn oru a this permit ahap be iop _FqU W-H•---._� _ - �- -��""- - - "' '�� - -
--- —_.__ - . " - .
deemed revoked- .-- - -.� --�—�---..- - - - `- CITY- Tel.No. �
MopA _fan _Other_
- 1lCEN5E6 CONiRACTORS DECLARATION ucENSE OR p
1 hereby ofFirm thot I am licensed under prov�sions of Chap�e�9 �'�� —Room Air Cond. — REG.NUMBfR � ��Ou•!� r
(commeneing with Ssttion�T006}of Division 3 of the Business power Apporatus 8 large Appliances DISTRICT NO. PROCESSED BV (L �
and Professians Code,and my license is in full Porce and effect.
Size 6 Type MP,KW,KYA,or KVAR C� �
license N�mber �9 3�� Lic.Closs� Up�o i IncL FINAL 4^ �
� i�� C1_ ` Ovor t to 10 fntl. OA� � �� - VALIDATIOH � �s
� Controctor�� C�i�"�`°'�'�a�e �'� Over 10 fo 50 Incl. V 4
❑ FlNAL W �
t am exempt under Sec. Over 50 io 100 Inc. BY � �
B.BP.C.for tbis reoson ��e��� z 4
Services,Swbd.,MCC 8 Panelboards � �
' �O�°' 0-2(10 Amp.Under 600 V
: Signature '` 201.1000 Amp.Unde�606 V �
. O . . Over 1000 Amp.ar Ove�600 V z 1 b t 0 p �
: EFempt�on for Reg.Maint. lect.
' SIIVGLE FAMILY Temp.Power Po1e 8 Appurlenonces � � �� � � � �2 �
! HOME OWNER-BUILDER DECIARATtON
Sign with One Branth Circuit � a e 2 rJ.�Cj
' 1 bere6y affirm ibaf I am exampt from the Contmctor'a Lice�se qddilional Sign Branch Circuits
'�� �pw,{«�}�e following reason (Section 703 1.5, Business an d �,,,,�, �
� Vrofessions COde):
. a.��5..:.,�
� ❑ 1,os owner of the properry,will do Ihe work and the Misc.ConduiR 8 Canducrora
� structure iy not intended or offered for sale(Seclion Other�See Complete Fee Schedu�e)_ � ��'���R� �
7Q4d, B�siness and Professions Code).
CONSTRUCTION LENOING AGENCY
1 hereby affirm that there is a wnshuction lending agency for
�he performonce of rhe work fo�which this permil is iuued PERMIT FEE (Su6-Toial) /��
�Sec.3097,Civ.C.).
PLAN CHECKING fEE
Lendei s Name
PERMIT ISSUING FEE IO
lende�'s Address ��
I cenify ihat I hove reod ihis application and sto�e tha�the TOTAL FEE
obove informa�ion ia corred.1 ogree ro comply with all Counly
ordioonces and Stme lows regoloting Electricol wiring,and
hereby authwize representa�ives of this County to enter�pon
the above-menfioned properfy for inspection purposes. SEE REYERSE POR EXPLANATORY LANGUAGE /�
G� 9-Y�._ !
�gnaWr er ee Date
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