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Home My WebLink About1155 SOUTH DIAMOND BAR BLVD (18) _,. ._ ._ . ; - _... .-----.� � � . . , . WORKER5 COMPENSATION DECLARR710N� � � M 76A663 ;o�e�'��"��APPLICATION�FOR��EL�C��L P��t�V11T -� � �� - � � .I here6y affrm thot I hove a ceriifimie of consent ro self �E e06G i�sure,o�a ce�nfimfe of Wo�ke�s'Compensatwn��so�ance, COUNTY OF LOS ANGELES � BUILDING AND SAFETY or a cert f ed copy ihereof(Sec 3900,La C j • , � p� .. .. ...._: .,,._. ..: d. .:•.w.. .r..ex,: . ,.t.. -„ci...-.��"�' �:%i^�'a�;;.s:s' � � Pelicy N�u` � CoripanY .POR.APPU[AM i0 FILL'IN . JOB ,.��;��•��r�'� Y p�n�� Certified copy is he�eby furnished. New Residenfial Bldgs.&Pools F/+GH �NO. FEE� ADORE55 v � Cerrified copy is filed with!he co nty 6 ilding insper 1&2-Family,Sq.Ft. � = 5 LOCALITY i NEAREST � lio depa� t. � Multi-fomily Sq.FL CRO55 5T: Resideniicl Swimming Pools OWNER OR Date � � � APPiicant - '< FIRM NAME CERTIF CA OF EXEMPTION PROti1 WORKER5`-�� Outlets:Rec Light_Sw. �� r^ �p� �! COMPENSATION INSf1RAh10E � � � aDORE55 1 Z 3 c � �Y��yti{ This secfion need noT 6e com lefad if Ihe work involved b Firit 20 � P Y Totol No.� Additionol CITY �` tyy,� 7e1.No. !�! SL'�'L }he permi}is for one bundred dollars(f100)or Iess.J PLAN CHEC ��/ � t/_;, � �ceriify thot in the performonce of fhe wo�k for which this APPLICANi Gt^C'LL{s^' �r�•�'"J'C i permit is issued,I shall not employ any person in any monner sa as to 6ecome sublect to fie Workers'Compensofion Laws. Liqhting Fizlures First 20 AD�RE� � C�L/ �,�, �r,�,�,Q,> Total No. Additional CITY � �Tel.No.g"' J f Date Applimnt Fixed Applionces Noi Over i HP ' PERMIT � NOiICE 10 APPLICANT:If, oNer moking fhis Certificote of APPLICAN7 'Z�Q..w� Ezemption, you should become subled to fhe Workers' Range�Heafer_D.W.— - - Compensofion pro�isions of the Labor Code,you must forth- Oven _Dryer _W.M..— ADDRE55 �.,t,�n _ with comply with such provisions or this permit shall be Top —fAU —W.H.� - _ _.,.... . . deemed revoked. Hood _ CITY s��,,H,_{.f Tel.No. . . . ... ...... ... ..... —Fan Other� . . _._.._,.,,...__...,.,..,.-. LICENSEDCONTRACTC$RSDECIAkAT�bN� Disp. _RoomAlrCond. — LiCENSEOR �� Closs. �' I hereby affirm fhot I am licensed under provisions of Chapter 9 REG.NUtitBER (commencing wlth Section 7000)af Division 3 of the Business DISiRICT`NO. PROCES ED 8Y p}.' Power Apparatus&large Appiiances ond Professions Code,and my license is In fuii force and effect. � (� Size&7ype HP,KW,KVA,or KVAR C3 License Number O L ` Lic Closs�_ PINAL � Up to 1 Incl. � Controciar --- Date Over 1 to 10 Ind. DATE �J'./ .�� yp IDATION � G ❑ Over 10�0 50 Ind. FINAL W� I om exempi under Sec. Over SO to 100 Inc BY � N 8.&P.C.for ihis reason . Over 100 � -�Do�e: Services,Swbd.,MCC&Ponel600rds ► � 0-200 Amp.Under 600 V Signorure �- � - �----�--•.-�--��•�� 201-10pp Amp.Under 600 V� ❑ Over 1000 Amp.or Over 600 V Exemp�ion far Reg.Moint.Elect. SINGLE FAMILY . . Temp.Power Pole&Appurtenontes HOME OWNER-BUILDER DECLARATION`� Sign wiih One Branch Circuit I hereby affirm rhot I om exempt from the Coniracror's License Addltional Sign Branch Circulls Law for ihe following reason(Section 7031.5, Business ond �9�i J�J A Professlons Code): ❑ I,as owner of�he property, �II do the work and�he Misc.Conduits&Conducrors pj 5 e c+ a a'� struciure is not inlended or offered for saie (Section O�her(See Complete Fee Schedule)_,. 7044,Business and Professions Codej. , � � °��.Q� CONSTRUCiION LENDING AGENCY°-"�� 'G i:O O� I hereby affirm thot there�s o mnstruction lend�ng agency for '�` ""`""" ihe performonce of ihe work for which rhis permit is issued PERMIT FEE (Sub-7otal) � �E.2 Q•-8 fj (Sec.3097,Civ.C.J. PLAN CHECKING FEE � Lender's Name .. . ......_._......o,..�-,. PERMIT ISSUING FEE �U Lender's Address ... ._>............._..,.,_>....„..,,. I cenity ihat f hove read ihls appiica�ion ond sra+e Yho�ihe TOTAL FEE �,,.� above informafion is correct I agree to comply with oll County ordinances ond State laws regulating Electri<al wiring, and hereby authorize representotives of Ihis Counry to enter upon ,a, , �,,,,,.,,,,,,r,,,. .,,., . rhe a�o�ment oned prope�ty for inspecfi n purp ses. � ' � � "'"""� -��`"�� SEE REVERSE�FOR�EX�L`ANAYORY"L`�`N'1GUAGE '� �.., gnoture Perm�nee 6 �D e � � . . . �---�-w....__,.__._._._:----_---,:.::� - ._ ..=�_�.__.:°_.k...c:4^..;�.-,., . ' , _ --,. , _ , . , _. , _ _ . .. ,. ; - - _,_. _._. ,_ v_ ._.. _._._�.. ... . -- — • - . . . -. _ _. , . � ' � - _.._._._.__._.. ._ ._...r � - r� + -t c h-- � � 3 . .'..:� � �..._ . '�_,_ .��,�.�� .. _. _ f i �, � i s . . • � . -,.�. ... .r, r a.- ^r ,. - , ..�,. .. ... .., . . .. , ...... � , .,. . . . �::- . I„______. _._z-.-.-.,.-.._._�.-__ ._ _'___�. ___. ' . .. .- >-¢>c `�'>Y..:-4�,u-.s r . . 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