HomeMy WebLinkAbout1155 SOUTH DIAMOND BAR BLVD (39) WORKERS'COMPENSATION DECLARATION 76A653 10i81 APPLICATION. FOR ELECTR.ICAL PERMIT '��
I h�"�eby aff��,rm �hat i have a certlfmte of consent to seif CE-806G
i�sure,o�a cen�ficafe ot wo�ke�s'Compensation I�s��a�ce, COUNTY Of LOS ANGELES BUILDING AND SAFETY
or a cerhfied mpy thereof(Sec 3800,Lob.C.) ��
U
Policy No. Compony FOR APPLICANTYO�FlCL IN �OB�
� Cerr,fied mpy is hereby fumished. New ResideNiol Bldgs.8 Pools EACH NO. FEE /{DDRESS /! S
� CertiEied copy is filed with Ihe county buflding inspec- 1&2-Family,Sq.Ft. $ — S LOCALITY
tion department. Muhi-family Sq.Ft. — NEAREST� � •
Residential Swimming 7ools OW ER OR ��iG
Date Applimnt �
FiRM NAME ^_ Z ��
CERTIFICA7E OF EXEM7TION FROM WORKERS' p�tle�s:Rec_Light_Sw._I MAIL n��
COMPENSATION INSURANCE Aoosesso�.7 3Z ��
This seceion need nof 6e com lefed if fhe work involved b FirSt 20 g C�
( P y Total No. Additional CITY���� � ��,� Tel.No.SC/Z'SS�e
fhe permif is for one hurtdred dollars(SI00)or less.) PLAN CHECK
�certify thot in ihe performonce of the work for which thls I APPLICANT
permit is issued,I shall nof employ any person in any manner
so as to become subjed fo fhe Workers'Compensotion Lows. ll9hiing Fixfures Firsi 20 ADDRESS
�Total No. Additionol
��_.7_.�� . CITY Tel.No.
Dore Applimn Fixed Applionces Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, a er moking this Certifimte of APPLICANT �/�,/ �
Exemplion, you should become subject to the Workers' Ranqe_Heater_D.W. _ q"�
Compensofion provisions of the Labor Code,you mus�forth- Oven _Dryer —W.M.— ADDRESS g�SS y-lU�
ith comply wlh such provisions or this permit sholl be Top _FAU —W.H.—
deemed revoked. Hood _Fan _Other— CITY T .No.�.c�s'- �
LICENSED CONTRACTORS DECLARATION LICENSE OR �J �/
I hereby affirm lhat I am licensed under provisions of Chopter 9 Disp. _Room Air Cond. — REG.NUMBER 'T 7�y Class.� �
(commencing with Section 7000)of Division 3 of the 8usiness DISTRICT NO. PROCESSED BY A
, and Professions Code,and my license is in full force and effed. Power Apparatus&Large Appliqnces f� U
�']' '/ /� �,[(' Size&Type HP,KW,KVA,or KVAR �
License Number .`��y� Lic.Closs� Up to 1 Incl. FINAL �
��T/�..lJ�7�S(El�te ��r7"�/v' O�'er 1 to 10 Incl. DATE , �, � U
Contracror YALIDATION �-
❑ Over 10 to 50 Ind. FINAL� �
I am exemp�under Sec. Over 50 to 100 Inc. 6Y fl-
8.8P.C.for this reason Over 100 N
Z
Date: Services.Swbd.,MCC 8 Ponelboards ►
0-200 Amp.Under 600 V
Signarure 201-1000 Amp.Under 600 V
OOve�1000 Amp.or Over 600 V
Exemption for Reg.MainL Elect j V��9 rt
SINGLE FAMILY Temp.Power Pole&Appurienonces
HOME OWNER-BUILDER�ECLARATION Sign with One 6ronch Circuit `� � S�' � };A e e r a'�
I hereby affirm thot I om eaempf from rhe Controctor's License qdditional Si n Brpn<h Circuits
Law for the following reason(Section 7031.5, Business and 9 � + a -rj 5�v Q
Professions Code;:
❑ I,ps owner of the property,will do the work and the Misc.Condoits 8 Conductors e m n�j,4j,�j O��,.
siructure is not intended or offered for sale (Section O�fier(See Complete Fee Sched�le)_ ,
7044,8usiness and Prafessions Code). � ��C�-��
CONSTRUC710N LENDING AGENCY
I hereby affirm thot ihere is a consiruction lending ogency for
the performonce of the wo:k for which this permil is issued PERMIT FEE (Sub-Total) �sl��
(Sec.3097,Civ.C.).
PLAN CHECKWG FEE
Lender's Name U
PERMIT ISSUING FEE
Lender's Add�ess �c-
I cerrify tha�I hove reod�his appli<6tion ond sto�e that the TOTAL FEE tiJS�Z
above informa�ion is mrred.I agree ro comply with all County -
ordinances and Stare laws reguloring Electricol wiring,and �
hereby awharize represenratives of rhis County to enter upon � � ��- � � � � � ' �
theA above-mentioned/p"7rope�ty far inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE �
�Gi�/ [�rL.�l2-�i(� f 1—7�"S�O
�c�noture ef Permirree Oate
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