HomeMy WebLinkAbout1155 SOUTH DIAMOND BAR BLVD (44) WORKERS'COMPENSATIONDECLARATION � 2°-°m°°=`m3'e� qpp`�Cps�101V FOR ELECTRICAL PERMIT �
I hereby affirm thar I hove a cerrificale of consent to self ceeob� �
msure,or a certifkate of Workers'Compensation Insurance, COUNTY OF�OS ANGELE$ DEPT OF PUBLIC WORKS
or a certh ed copy ihereofi(Sec.3800,Lab.C.) ,.,,,.�.-.;�..a.._,-.s;_e.a.�»-�."�,.a.b::-.�..., �,�,� -�..-R,.4.;���:r e�k;'��' ..."�3?�"L�> fri
. � Policy�Nd, '� Company' . FOR APPLf[ANTY6 Fllt IN �OB
�Cerilfied copy Is here6y furnlshed. •� New Residenhpl Bldgs.8,Pools EACH NQ PEE A�DRESSf;,' ;.�
`(�Certified copy is filed with the coun�y building inspec- �&2-Family,Sq.Ft. 5 — $ IOCALITY
F `�-'tondepartment. Multi-familySq.FL — NEARESi
�'� %.s�. Res�deniiol Swimming Pools CROSS SY
, DatA"�"- ApPlicant ., - OWNEe02 _
_,_,. FIRM NANE _
CERTIFICATE OF EXENIPTION FROM WORKERS�� Outlets:Rec—LigM_Sw.� '''�A��
COMPENSATION WSURANCE Pirs120 .4DDRE55 ' -
(This saction need not be completed i{fhe work imolved 6y Totql No. Add�iiionol CITY Tel.No.
the permit is For one hundred dollars{5100)or less.) p�AN CHECK
' I cerr�f rhor In the erfo:mance of rhe work Por which�his -^�""""` ....
- Y P APPLICAN`
. , .._ .. ,.. .
. permlt Is�iss�ed,I shall noi employ any person In ony manner �igMing Fixtures First 20 ADDRE55..-......•--..
so as to become sobje<t to ihe Workers'Compensalion Laws. . �-
Addi rional
7otal No. CITY ..•�--^•^•^�M- Tel.No.,�„„v.,...,....
Date Applican? ���- " fixed Appliances No!Over 1 HP pERMIT
...,. ,..�:�,. .....
NOTICE TO APPUCANT: If, after making fhls Certifim+e of -
Exemprion, you should bewme wbjed to the Workers' Range— Heater—D.W. � APaLICaTION�
Compensation provisions of 1he La6or Code,you musf forth- Oven — Dryer _W.M.� ADDRE55��.� . ��.�,��
ith comply ith su<h provisions or lhis permit shpil be Top —FAU —W.H.— ' ' '`--- -
deemedrevoked. QTY� Tel.No. -
Hood —Fan —Other—
LICENSEDCONTRACiORSDECLARATION _ _ REGNNUMSER � ......_.-,�., _. �
Disp. Room Air Cond. Clpss.
I hereby affirm thoi I om iicensed under provisions of Chop�er 9 - �-��-
(mmmenang with Section 700D1 of Dlvlsion 3 of the Business Power Apporqf�s&4arge Appliances DISTRICT NO. PROCESSED BY 2
and Professions Code,and my Gcense is in£ull force and effect. � Q
� Size&Type HP,KW,KVA,or KVAR .- V
- license Number .. � Lic.Closs � ' �� = Up�o i Ind. FINAL Y J
��s-� Over 1 to 101nd. �'QTE VALIDATION
ContraUoi� Dare � � `��;'`�.��'�. LL
� ! . .,� ...,,i..
� � � Over lO to SO lnd. ��Np� r
❑ I om exempt under Sec Over 50 fo 7D0 Int. gy �
-� " � Over 100 � �
B.&P.C.�for this reason .
__.....,..,._..:,.,..
Services,Swbd.,MCC&Panelboards � �
,.. .--:.•�:->.•�.'Date: 0-200 Amp.Under 600 V
Signature - 201-1000 Amp.Under 600 V W
DOver 1000 Amp.or Over 600 V i-
Exemption lor Reg.Maim.Elecf. `-�_
� SINGLE FAMILY � ��
HOME OWNER-BUILDER DECLARATION Temp.Power Pole&Appurtenpnces s��,�,.e
I hereby affirm thai i am exempt from the Contractor's Llcense Sign with One Brancn Circuit ��� �� �--
Low for the following reoson(Section 7031.5,.Business and Addifional Sign Bronch Circuits �, p'._ �_i,
Professions Code!: .
❑I,as owner o£�he property,.will do the work and tne Misc Conduits&Conductors m° � ����'�� ?
� sirodure is not intended or offered for sale(Section 7044, Other(See Complete Fee Schedu�e)_ � � : �t r cr�.,
8usiness ond Professfons Codel.
CONSTRUCTION LENDING AGENCI' � '�- "�'"'' �"`-�"
I here6y affirm ihot there is a consiru<lior.lending agency for -
the performance of the work for which rhis permit is issued PERMI7 FEE (Sub-Total;
i5ec.3097,Civ.C.).
PLAN CHECKING PEE
Lender's Nome - s
. . � PERMIT ISSUING FEE -
Lender's Address .,. �
I certity that I have read this application and state ihat 7he TOTAL FEE ... ,..,...s;.x- ,: ,:._;.,?...,,_p_.�:4�..T'�,`.,,'.,��:�•.i'
obove informafion Is correct.I agree fo<omply wirh oll Counfy '
ordinances and State laws regulaling Elecfrimi w ring,ond
hereby au7hor¢e representotives of�his Counly to enter upon , .. . . :.. . ..... . :.. ..... ..
the obove-meniioned p�openy for inspechon purposes. ��' � ��-� �� +��----���`"�'��' '����` "" '
. . SEE REVERSE FOR$XPCANATOkV�LA�GUA�s�E�
. : .� ;�.�'., ; , � . _,�,
_.... ,. -..:� -..,. .r ..�:.,, .,. ..
Signoture of Permittee Date . . � ���s
I . ..._.-. .,.:,... . ..,.- . . " .-.,. . ... . ... _. . ........... ... . ' .
. - '..lilC. .. .