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Home My WebLink About1155 SOUTH DIAMOND BAR BLVD (54) .. � WORKERS'COMPENSATIbN�ECLARA710N� �� 76A663 7oisl " '" '"� � ' " �� -`�°�.'�'. � .�.��-��- - ... .. , >. . : i hereby afF rm thar I hove o cerlificate of consen'to self �E-� - APPLiCATION FOR��L�C�'1�ICi�L PER�i'Ihh"� - Y �� insure,or a cer�ficote of Workers'Compensatlo�I�s��ance, � , . �COUNTY pf LAS ANt'aELES` � �� BUILDING AND�SAFETY �� or a cert�f ed copy thereof(Sec.3800,Lab.C.1 A . ... ._ ... ._ .,.,... ...._...,,.._.x... .. . _.. . �.,..._....�.,:< �.r. . . . . ��-.s:b�-�:�.:...:.�t.... P�ol'icy No��nmppny�/'t�r�2 L�Fi�. FOR APPIICAN7 TO FIIL IN , 108 ` Certified copy�s nereby furnrshed. EACH �NO. FEE � ADDRE55 / ,� S /AXqOA(j, �1j New Residenfiol Bldgs.&Pools � 1&2-Famil — LOCALITY Certified copy is filed wirh rhe<ounty building mspeo y,Sq.Fi, g — $ f Nsd�viJ hon eepartmenr. Mu�fi-fomily Sq.F. .NEAREST ��-�, .�` � Residential5w�mming Pools OWNEROR /� .. . .._.. .._... Dare A Ilcant G'- � p PP FIRMNAME �✓�� CY ��SC ERTIFI ATE OF EXEMPTION FROM CNORKERS'� N�AIL COMPENSA710N�INSURANCE�� Outlets:Rec_Light_Sw._ qDDREss /�,,,r This section need nof 6e com lefed if fhe work involved b First 20 � P � Y Totol No. Additional CITY Tel.No. 1he permk is for one hundred dollan(S10D)or less.) � �'-" --�'-��-'-`- i cer�if !hot i the erformonce of the work for which this PL4N CHECK Y P I APPLICANT permit is iss�ed,I shpll nor employ any person in ony manner so os fo become subiecf to ihe Workers'Compe�nsoilon Laws. Li9hting Fixtures Firs1 20 ADDRESS � � Total No. Add�dlonai �� CITY Tel.No. Date Applicant Fixed Appllonces No�Over i HP aERMIT NOTICE TO APpIICANT: If, after-making-this Certificare of APPLICANi /Aj � S Exemption, you should become subjed to the Workers' Range_Heater_D.W._ Compensa+ion provisions of the Labor Code,yau must forth- Oven _Dryer _W.M._ � ADDRESS � s with mmply wirh such provisions or this permit sholl be Top _FAU —W.H.— deemed revoked. Hood _Fan _Other� CITY Tel.No — ' LICENSED CONTRACTOR5bECLAfiATION�� - LICENSE OR l Disp. _Room Air Cond. — REG.NUMBER ,7 �� C1 Class. �,L�R I hereby pffirm�hot I qm licensed under provisions of Chap�er 9 �� (commencing with Section 7000)of Division 3 of the 6usiness power A DISTRICT NO. PROCESSED BY 0-� and Professions Code,ond my license is in full force and effect. PPo�aWs 8 Lorqe Applionces �' �f� Size 8 Type HP,KW,KVA,or KVAR t'�2 r't-�- V License Number� jT=y� Lic Closs � S Up to 1 IncL FINAL � �,yf��c� �i/�l��f Over 1 to 101nd. �ATE `��_� VAIIDATION � Controctor !VT �'18f€/� f.� Over 10 to 50 Ind. aFIN � I am exempt under Sec. Over 50 to 100 Inc. BY � 8.8P.C.for this reoson -� � - Over 700 Z Date: Services,Swbd.,MCC&Panelboards ► 0-200 Amp.Under 600 V Signature - 201-1000 Amp.Under 600 V <3 G 9,7 A O - � . Over 1000 Amp.or Over 600 V Exemption for Reg.Maint.Elect. �° ' '��2 SINGLE FAMILY � � , , Temp.Powe�Pole&Appurtenonces i ° °�G 5..�i G HOME OWNER-BUICDER D�ECLARATION Sign with One 6.onch Circuit I G s I hereby affirm that I om exempt from the Conirocior's License � � z G 5.J J�= Low for the following reason (Section 7031.5, 6usiness ond Addi!ionai Sign Branch Circuits Prafessions Code): i I 0.2 2—8 6 ❑ �,as owner of�he properry,will do the work crnd the Misc Conduits 8 Conduclors stru<ture is nol intended or offered for sale (Seclion Other(See Complete Fee Schedulej_ ► �044,Business and Professions Code). CONSTRUCTION LENDING dGENCY��- �� I hereby affirm rhat there is a construction lending agency for the per4ormance of fhe work far whrch this permit is issued PERMIT FEE (Su6-Totd1J j ISac 3097,Cfv.C.) - � PLAN CHECKING FEE Lender's Name� PERMIT ISSUING FEE !O S� Lender's Address r, ,o I certify thar I have read this applimtion and state that the TOTAL FEE S +S above in4ormotion is corred I ogree to compiy wilh oll Caunry ordinances and State laws regulating Elecfriml wiring,and hereby au�horize represent ives of ihis County to enter upon fhe ve-mentioned pro ty for inspe,t�o urposes. ' � _. .. ._..... ... .... . .. ..... . . ... .. .. � '"C �'4i��I�,,�' SEE REVERSE FOR EXPCANATORYLANGUAGE... ... SignoWre of P�Iminee Da . _ ' ...,_•__•_•.___................_._._._..._�.�...._........��.._.,.-.._�.;;.;cx-�-....:�-....., . , . . . . ' t ��H��. - 7�r� -. ' . . , ,._ ' . .-..� . .,v_, �ft .. � � :,^•.! :j. . _. _ � �r � v, •< .. .. . 'l..'.. .. . ..�._ .......... .....�._...,, ....-_. . 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