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Home My WebLink About1633A (225) WORKERS'COMPENSATIONDECLARATION 76A6N �o�e, APPLICATION FOR ELECTRICAL PERMIT � I hereby oHirm thot I have a cerlificate of consent to self �E'�' irisv�e,or n certificafe oi Worke�s'Campensa�ion Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY oi a cerfified copy ihe�eof(Set.3900,Lob.C.) ' P❑olicy No. Company FOa RPiIIGNT TO itLl IM DDRESS lJ ( Cerfified copy is hereby fu�nished. New Residential Bldgs.8 Po EACH NO. FEE � • ` � CerfiFied topy is filed with Ihe co�nty building Inspec- 1 8 2-Family,Sq.Ft.� E — E �OCAl1TY ��,�,� rian deparlmenl. � Mulli-famity Sq.Ft. — NEARESr CR T. � /�– � Residentiol Swimming Pooli � Date Applitont , AME CERTIFICATE OF EXEMPTION FROM WORKERS' � � � huit � � Ou�lets:Ret ligh� Sw. s ' COMPENSATION INSURANCE �j� Firsl 20 ADORE55 �.�3 /C (Thli�ection n��d nof b�complahd II th�work involved by Totol No.�_ Additionol CITY � R�TeI.No.��ZZ9 ehe permi}ts for one hundrod dellan(5100)or I�� PtnN C� I certify rhat in the periormonce of�he w er 1hi5 � APPLICANT permit is issued,I 5hall nof employ ony n on o � so a�to�ecome subjeU to 1he Wor _ en on L� Li9hting Fiztures First 20 ADDRESS Z ly/ �� Totol No. � Additional Oate pplicon ��' CITY Tel.No. NOTICE TO APPLICANT: If, aAer maki is Cer�ifica�e Fi.ed Applionces Not Over I HP PERMIT , 1 E�emption, you should become subjed �o ihe Worke Range_Heoter_D.W.— AafLiCANi W Compenwtion provisions af the Lobor Code,you must Tort • Ovan _�ryer _W.M.— ADDRESS wilh wmply with such pravisions or this permit sholl be Top _FAU __W.H.— deemed revoked. Hood _Fan _Olher_ CITY Tel.N0. IICENSED CONTRACTOR$DECLARATION LiCENSE OR I hereby offirm ihat I om licensed under povisions of Chapter 9 Disp. _Room Air Cond. — REG.NUMBER Closs. (commencing wiih Section 7000)of Division 3 of�he Business Power Apparotus&Large Appliances DISTRICT NO, PR E BY Y ond Wofeszions Code,ond my license is in fuil force and effaU. Size 8 Type HP,KW,KVA,or KVAR� O � O License Number Lic.Closs Up�0 1 Incl. F�NA� V Controcror pote Over 1 lo IO lncl. DATE VALIDATION � O Over 10 to 50 Incl. � FINAL I om e.empl under$ec. Over 50 to 100 Inc. BY . � 8.8P.C.for Ihis reason Over 100 y - � Services,Swbd.,MCC 8 Vonelboards , �� Z Da�e: 0-200 Amp.Under 600 V , S�gnature �DI-1000 Amp.Under hW V � OOver 1000 Amp,or Over 600 V Eaemption for Reg.Moinl.Elect. � SINGLE FAMILY Temp.Power Pole 8 Appurlenances HOME OWNER-BUIIDER DECLARATION Sign wilh One Branch Cittuil I hereby oftirm Ihat I om e.empl from the Coniroctor's License Additional Siqn Branch Circuits Law for the following�eoson(Seciion 7031.5, Business ond (P��oyfess�ons Code): � LJa�I,os owner ol�he proper�y,wili do the work and�he Misc Conduits 8 Conductors -� struc�ure is not imended o�a(fered for sole(SnU�on Orher(See Complere Fee Schedo�e)— ► �� 6�v� 70�4,Business and Prafessions Cade). CONSTRUCTION LENDING AGENCY �� . � �2 r,.. I hereby offirm thot there is a consrruUion lending agency for � a •2�,•�5 Ihe performance o{the work far which this permil is issued PERMIT FEE (Sub-Totol) . (Sec.3097,Civ.C.). _ PIAN CHECKING FEE . °2�'7 J�' �ender's Nome �Z� �_g 4 PERMIT ISSUING FEE lendei s Address , I cenify�hat I have read this opplicauon ond state Ihat�he TOTAI FEE obove info�marion is correct.I ogree ro mmply with oll County . _ ordinances nnd State laws re ulaling Eledricol wiring,ond � hereby aul rize re n otives o is ''nty 10 enrer upon � ihe abov - ereio properry r' on purposes. � SEE REVERSE FOR EXPIANATORY LANGUAGE �jss- s– �? 'L $ig ture oi P�' –�- Date ' p G m � T ` � O v Z T -C-+ � � �° C m O y � � G Z. = eAi� t' „Yv N r „� 7o m 'n n .� 0 v C� G u. � Q p O � "' o p v � � = G � � � � � N "^ m� ' v " . � � n � � ? � ,, ��n m � �4� � � � � Z a �u m i . • o � w r� v �= O O O �- � � 7 � � O {n? 0 7 W O u �'3 +�+u.'6 ti N � � . . � a O p N �G. O f 3 � O Q N n y� L� �T n 7 n '_'?.�• V' � Q... O � � 3 Q'm00.SC�O�aNp�O �o�.SO �ofl"£ T � �1J C G m 1� �C y' O O�^ C b�c �'��i 1J � cu � X a.'cv 3 n-3 °-' � p �o��sn o �-�'�-v 3 0 � n C� O� O C7 . �.� n -` " 7 O ^� 3 � ��«O �� £y'D'nU 0.Q p��a f� t n O M O � � � � � � N � O � N ° ^ ' 3�°-% S N`° � p n ; N O� G G N 3n, o � mo rm r � o =oa ^ao ��, � 3 _.oa �-N � o- � ' �' � < �n.o m o N � � s '� =v� a f� ��n � o f,o ,�, n ❑ °" a' a, o �+n N �r n.> � . Q N o o �- N ��a� ..,o � � �sc'o ° _'�.� 3 r� p n ; s.�o y 000- aa 3 ooc� o n T o v� ro � D a v r � a vo � °�N�o m � s o 3,° � � o .., y c � ^c n.� 0 3 .K s� o' " - 't o o 'o � o ' o o -t o 3 Q c� ,c g� ^_. � 3 q °-.� a T� o N � c �� o � S N �� ° o � �� ° � o�-� �-coo � o� maoo� o O ��T� o ao �o o ��o� « 3 °M � o 0 o n o n '` O � Q Q � '^N 7 �-O = "'? tS 0.� 7 7 � ��3 m o ° o s!' � ° �-�'sa�N Q-°, �� o0 �� C-� d-^10 0 '7 O N Q �� O �^ O O �,�p � C ' v � O p.� N O j F �ro n V o f �'q� ?T�w S> _ � w� ' p �b O _ v� S O W ' I p , C O 0. � .' � e. a s o o �.� " ,-� . a�+ ��"''r-�'..