HomeMy WebLinkAbout1155 SOUTH DIAMOND BAR BLVD (59) WORKERS'COMPENSATION DECLARATION CEBOaG a 87 APPLICATION� F�R ELECTRICAL P�RNIIT� � - �
I here6y affirm ihat I have a cerritimre of mnsenl to self �
insu�e,o�a ce�ritkare oi Wo�ke�s'Compe�sation I�surance, COUNTY OF LOS ANGELE$ BUILDING.AND SAFETY
� or o certified copy�hereof(Sec.3800,Lab.C.)
Poli�y No. Company FOR APPLICANT TO Fltl IN JOB � .
� � Certified copy is hereby furnished. New Residentiol Bldgs.&Pools EACH NO. FEE A��RESS
� � Certified copy is filed with ihe county building inspec- 1 8 2-Family,Sq.Ft. 5 — 5 LOCALITY
—I NEAREST
tion depa�imeni. Multi-fomily Sq.Ft. . .,
" Resideniiol Swimming Pools CRO55 S7.
Date Applimnt OWNER OR
FIRM NAME
CERTIFICATE OF EXEMPiION FROM WORKERS' MAIL
Outlets:Rec_LighP_Sw._ i -
COMPENSAiION INSURANCE � ADDRESS � �
First 20
(This secfion need nof be compleTed if The work involved by To�al No. Addifional � QTY Tel.No.
the permit is for one hundred dollars(5100)or lass.) i PiAN CHECK
� I cerrify ihar m rhe performance of the work for which this qapuCnNi
, permit is issued,I shpl I not employ any person in ony monner ,�
so as to bemme subjecl to the Workers"Compensalion Laws. ��9hting Fixtures Firs�20 - ADDRESS
^ � ` � Additional
� q .1`� ,:' �. ..�'"� .-':�f'.t;::'�',;:�..:;,�; Tatal No. _ CITY Tel.No.
Dafe " Applicom � ' --' Fixed Applionces Not Over 1 HP PERMIT �
. NOTICE-TO APPLICANT: If, aNer rr�ak�r,g ih�s Certifimte of APP���qNT
Exemptfon, you should become subjecf ro the Workers' Range_Heoter_�.W. _
� Compensation provisions of the Labor Code,you must for�h- Oven _Dryer —W.M.-� � ADDRE55 � ' _
� with comply with such provisions or ihis permif shall be Top _FAU —W.H.— I
deemed revoked. I � CITY Tal.No. Q
LICENSED CONTRACTORS DECLARATION Hood _Fon _Other_
� Disp. _Room Air Cond. — LICENSE OR Class.
' � I here6y affirm ihor I om li<ensed under provisions of Chopter 9 REG.NUMBER p
� (commencing with Section 7000)of Divis�on 3 of the 8usiness pawer A DISTRICT NO. PROCESSED BY �
. ' and Professions Code,and my license is in full force and effect. PParatus&Large Applionces �
Size&Type HP,KW,KVA,or KVAR �� � :�!
, License Number Lic.Class Up to 1 Ind. F�NF+� �
. - Over i io IO Ind. DATE �
Contractor � Dote � VALIDATION
. ❑ , Over 10 to 50 incl. fINAL �
I am exemp�under Sec. Over 50 to 100 Inc. 8Y
� 6.8P.C.for this reason Over 100 �
� Date: Services,Swbd.,MCC 8 Paneiboards ► LL1
. 0-200 Amp.Under 500 V �'
I, Signature 201-1000 Amp.Under 600 V
r-� Over 1000 Amp.or Over 600 V
U Exemplion for Reg.MainL Eled. I .
, , SiNGLE FAMILY iemp.Power Pole 8 Appurtenances � � � ��
_ HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit '-�e =
I hereby affirm thor I am exempt from the Contracior's License qdditional Sign Bronch Circoits ' K
� Law tor the following reason(Section 7031.5, Business and , ' `;._F_,�..r.:
, Professlons Code): '"'
❑ I, as owner of the property,will do ihe wo�k and the Misc.Condui�s&Conduc�ors I ,_« u.,_,2'_<<,_
structure is mt intended or offered for sole(Section 07her(See Complete Fee Schedule)_ ► ,
7044,Business and Professions Code). �- ��"�� � `� ��
CONS7RUCTION LENDING AGENCY
I hereby affirm!hat ihere is o mnstruction lending agenty for
the performonce of the work for whlch ihis permit is issued PERMIT FEE (Sub-Tota,) .
(Sec.3097,Cio.C.).
- PLAN CHECKING PEE
Lender's Name
PERMIT ISSUING FEE �
' Lender's Address
I certify thqt I hove read this opplica!ion and sfate fha�the TOTAL FEE � .
� above informatlon is correct.I ogree to comply wifh all Couniy �
� ordinonces and State laws reguloting Elecirical wiring,pnd �
, hereby aulhorize representotives of+his County fa enfer upon
, the above-menrioned properry for�nspection pu.poses. SEE REVERSE FOR EXPLANATORY LANGUAGE
' . ... ' � . .,-;t�
' $ignoture ef Permittee �a1e