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HomeMy WebLinkAbout1155 SOUTH DIAMOND BAR BLVD (22) a'��` -° WORKERS COMf�I;ATICyV D`CLARATION 76a6G7 ,0:8, - - APPLiCATiON-��FOR������'��R�`C�L � � T � �����„c �•vV� � ., , m . he�eby aff rm thoi I ",;vc a cert f cate of consent to self CE-806G ��� � insure,or o cert�f wte of WorKers'Compensalion Insurance, -�' � ' � ������ -� � � or a�en(ed�opy rhe.eof(Se� 3800,Lab.C.1 GOUNTY OF O.OS ANGELES BUILDING AND Si4FET ;,.. ^ �°�+'s w- .,.,.: .. . ...... : q,� . _ �a . P❑ollcy No. Compony . FOR APPLICANT TO�FILL IN ... JOB / (/' / C'1vc7 Certified copy is here6y fumished. New Residen�ial Bldgs.&Pools EACH NO. FEE ADORESS �_�.� .� , �j � c 1&2-Famil LOCALITV� Certi.ied copy is filed wi�h the coonty building inspe<- Y-S9�F�� 'S — S ����(J� NEAREST ' ,/���/� tlon departmenL Mul�i-fomily Sq.FL CRO5557. � //✓v Dote q licani Residenhial5wimmingPoois OWNEROR � �—� Pp i �FiRM NAM Cr %EG�G.�l.� / �Cf�f�TIFICAiE�OF EXET7iPTI�IJ"�`�2fSAA'WOkICEl2��'�� - � MqiL �t! �OQ«^V COMPENSATION�INSUR�ANCE'� Outlers:Rec_�___Light_Sw.__ I qD�RESS Z����� �17/.+i� �'L f��° (This section naad noi be completad if ihe work invalved 6y Firs1 20 - r The permiT Is for one hundred dollors(5100)or less.) iotol No.� Addificnal GTY/�,�9-�f�i(•y� G�+ iel. .��_�.t� . I cerrif thot in ihe erformance of�he work for which this � GLAN CHECK . Y P APPLICAN7� permit is issued,I shall not employ any oerson in ony ma �- so as to become subject fo the rke Comp salion Lighting Pixt�res Pirst 20 ADDRESS f��� � Additional ' . ... -".. .'.- .,_� J/�� �^�/' f/V C r � Total No. ❑TY Tel.No. Date[J-L_��.�._Appllm Fixed Applionces Not Over 1 HP I 7ERMIT /�r- ~d �Y NOTICE TO APPLICANYi If, af(er mo ing fhis Certifimte of �APpLICANT J �(Jf/4 Exemption, you should become subjecf to the Workers' Range_Heater_D.W. _ ,f' Compensation provisions of the Labor Code,you must farth- Oven _Dryer —W.M.— ADDRE55 with comply w�th such provisions or this permit shqll be Top _FAU _W.H.— I ' � " i .. . .. . .........s.,. deemed revoked. Hood _ CITY Tel.No. ..-. .._......_. ,Pan Orher— . ._. .,..,,...... LICENSED CO�NTRAC7bR5'CSECLA1FAiP01�"���� LiCENSE OR —7 n Dlsp. _Room Alr Cond. — Z'S Class. � I here6y affirm that I am licensed under provisions of Chopter 9 REG.NUMBER� � / C��/ � (commencing wirh Section 7000)of Division 3 of 1he Business power Apparatus&Large Appliantes DISiRICT NO. PROCESSED BY a and Professions Code,ond my license is in full force and effect. O J� �� c—f Q Size&Type HP,KW,KVA,or KVAR � U Lic nse Number Lic Class FINAL �[� � Pi_������ Up to I Incl. DATE l.1� � �Y� Over 1 to 701nd. .-v r�.� Contracfor��—�'�'L�C Dote ����7� � B VALIDATION OOver 10 to 5�Ind. FINAL W I am ezempt under Sec Over 50 to 100 Inc BY �Y � B.BP.C.for this reason Over lOD � - Dare� Services,Swbd.,MCC 8 Panelboards � 0-200 Amp.Under 600 V Signoture .......... .... _,_.,...._�,,. 201-1000 Amp.Under 600 V aOver 1000 Amp.or Over 600 V Exemption for Reg.Maint Elecf. SINGLE FAMILY . . Temp.Power Pole&Appurfenan<es HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuii I here6y affirm thoi I om exempt£rom the Coniroctor's License Additional Sign�Bronch Ci�cuiis .Low for the following reason �SeUion 7031.5, Business ond wofess�ons Code1: ��5 4.0 A ❑ I,os owner of the Misc Conduits&Conductors " property,will do the work ond ihe p�her See Com I �e Fee Schedule_ a s a a�s siructure is not infended or offered for sdle (Seciion � P e � , � � 7044,Business and Professions Code1. � CONSTRUC7ION LEN�ING AGEN�V� �- ��� f � � � ��2� I hereby affirm ihot there is o canstruction lending agency for e o c j j,i�� 'the performonce of the work for which rhis permit is issued PERMIT FEE (Sub-Total) (Sec.3097,Civ.C.1- I L I 7--8 6 oLAN GHECKING FEE Lender's Name .. ..-... ...�.. .._.�..�.�..... PERMIT ISSUING FEE � lender's Address . .I cerfify that I hove read�his opplicarion pnd state thot�he T07AL FEE a6ove informotion is correct.I cgree ro comply with oll County ordinon<es ond S!ate law reguloti lectrical wiring,ond h r y❑ nze repres i� tives of i Couny fo enter upon . � v - i e��p op rty for s ec�ion purposes. . *-•-.. �..:�... ^�� . .. . . .. . .. . . . ...,.,_ , ...._. _.. (J �y (�/ SEE REVERSE FOk E7CPCDiNi4i'OItY�-LANIGLA�E�� �i' E ��/��4 5� Signmure cf Permittee / Date . :,,....,_..,.:..,.-,....� . ... ..,..,,,�_, _ —_ .__i.. ...... „� .- . ... ._ . . ..,,.. .,.. .>.-. ...�'-,,.,mra+�ssan " +�m+ause3` •_ �aa. , . ...., ... :.� :�`.�'3';.���'i�6"d --' - - ._ .__...._ .. ,.._ , a __ . . . ., . ;f..�.�,-.,fi . ..� . . � t ,,,._., f.:". . .. I .,: . . ..__ __......._.__.�. . . .. . . � ,. . .>. . .. . . ..c. . . ' ....0 .,`�,�C^ ' , . -. ...� .._ . ___.... -: . .. _ 9 ' � . . . _. . - ' ... - ,._...�['..!. ' n // ' � 1i c t ) c ' • ' � ' //��[,( �y j�/'/ � . -I: : 7 . 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