HomeMy WebLinkAbout1155 SOUTH DIAMOND BAR BLVD (25) _ . ... _ ___ � _ �.
'NORKERS'COAAPENSATiONDECI,ARATION 75A663 �o.A,, qppLICATION FOR-ELECTRICAL�PERAl11T
� I hereby af�i�m rha� I hove a certificote of consent to self CE-806G
insore,or a cerrHm±e of Wo�ke�s'Compe�sation I�w�ance, COUNTY OF LOS ANGELES BUILDING 14ND SAFETY \.
or a certified copy thereof�Sec 3800.La6.C.) ����ff'
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P�olicy No. Compony iOR APPLICANT 70 PILL IN " JOB � �,� �,
Cer��fied<o s he�eb furnished. EACH NO.� FEE ADDRESS y�� �'Li'j_,:r/✓„����y:
PY' Y New Residentia)Bldgs.8 Paois
� Certrfied copy is flled with the county building inspec- 1 8 2-Fcmlly,Sq.Ft, 5 — 5 LOCALITY � �
tion depariment. Multi-fpmily Sq.Ft. — NEAREST .��f
Resident;oi Swimming Pools CROSS Sr, �'y �����
Date Applicant 1 OWNER OR ,y� � / ,� -
FIRM NAME ��"-�"`/'y�,s� �.�.s-�_�
CERTIFICATE OF EXEti1PTION FROM WORKERS' Outlets:Rec_Light Sw._ I MAfL � �
COMPENSAiION INSURANCE � � A�DRE55 ;i S :� �- �Gf-���y�/
First 20
(This secTion need not be comple}ed if the work involved 6y Total No. Addilionol CITY ,,��� 1��� Tel.No.
fhe permif is for one hundred dollars(5100)or Iess.) p�qN CHECK �
I certify that in rhe performance of the�work for which this I qPPLiCANT �
permit is issued,I shol�not employ any pers n in any manner
so as to berome subject to the Workers' pensa;pon Lows. Lighting Fixtures First 20 ADDRE55
� Additionol
Date:�'�'�'`'�,X-Applican� � � Total No. CITY Tel.No.
Fixed Applionces Not Over 1 HP PERMIT �}.-�_
NOTICE�TO APPLICANT: If, ofter riiokin this Certifi e of Q l"' �
Exemption, you should become subjecr ta the orkers' Range_Hea�er_O.W._ F+P7lICANT - �<�1/ �Y„1'�" !/` 1 ��"'�
�Compensation provisions af the Lobor Code,you us�forth- Oven —Dryer —W.M._ ADDRESS 1���--'� i" =;�?/_C_(}_ ;� j j
wi�h comply with such provisions or this permit shall be Top _FAU —W.H.— � �
deemed revoked. Hood _Fan _Other_ C�TY�LC���!<: Tel. - �.5%"'��-�-_� ;;�
LICENSED CONTRACTORS DECLARATION ' uCENSE OR
Disp. —Room Air Cond. _ �� ,�-_�,�� � ,' Class."
I hereby affirm that I am licensed under provisions of Chppfer 9 REG.NUMBER �..`�;'�
(commencing wi�h SeUion 7000)of Division 3 of the Business power Apparotos 8 Large Appliances DISTRICT NO. PROCESSED BY Or..'
ond Professions Code,and m license is in full force and effect. y
,/ Y Size E Type HP,KW,KVA,or KVAR �� `� � U
License N�mberUaE.�,rS ��'-�� Lia Closs �-� ���
� Up to 1 Ind. FINAL ry bC
Coniroctor���=-s�r C.P`�/'�4""�' Date ��'Q~� =�� Over 1 to 101nc1. �A� �' i�1 VALIDATION O
❑ G� Over 10 to 50 Ind.. FINAL W
I om exempi under Sec. Over 5010 100 Inc BY C
Over 100 N
B.&P.C.for ihis reason z
Daie: Services,Swbd.,MCC 8 Ponelboards ,
D-200 Amp.Under 600 V
Signature 201-1000 Amp.Under 600 V
❑ Over 1000 Amp.ar Over 60D V
Exempfion for Reg.Maint.Elect.
SINGLE FAMILY Temp.Power Pole 8 Appurtenonces
HOME OWNER-BUILDER DECLARATION Sign wnh One Bronch Circuit C
I hereby affirm that I am exemp�from ihe Contractor's License Additional Sign Branch Circuits
Law for the following reason(Section 7031.5, Business and
Professions Code):
❑ I,as owner of the o err Misc.Conduits&Conductors ,?4�C 4 H
pr p y,will do�he work and the Other See Cam lete Fee Schedule
str�Uure is not intended or offered for sple(Section 1 P )— ►
7044,Business and Professions Codel. �� v c c c c�
CONSTRUCTION LENDING AGENCY � � 6 G:'.5 V
i hereby affirm rhot there is a construction lendinq ogency for
the performance of the work for which this permit is issued PERMIT FEE [Sub-To�oll , ,; ���L�`
(Sec 3097,Civ.C.). � -"
PIAN CHECKING FEE �
Lender's Nome i t:� �`�`O
PERMIT ISSUING FEE C� �
Lender's Address
I certify fhot I hove read this applim�ion and srate ihat the TOTAL FEE ��'
above information is correcL I agree to comply with ali Counry
ordinances and S�ote laws re ulating Elecrrical wirinq,and
hereby aurh ze represent es of rhis County to eMer upon �
the obov entioned pr "rty for in ction purposes.
� ��r, � SEE REVERSE FOR EXPLANATORY lANGUAGE
�� �.o F T-- -;��
Signoture ef Permit ee jDote
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