HomeMy WebLinkAbout1155 SOUTH DIAMOND BAR BLVD (70) �� ' WORKERS'COMPENSATION DECLARATION � �� �� � 78.nec3 io�el � �" � ` ' "'�'� - �� '� - � � . .._, _ .. . .. . . . .. . I he�eby affirm Ihat I have a certifmle of consenf to self �E-806G APPLIG�lTi0�1�FOR ELE�TRICAL� PERMIT � _ � fnsure,or a certificate of Workers'Compensotion Insurance, COUNTY OF LOS ANGELES BUILDING A�ND SAFETY � � �� �� � or a certified copy ihereof(Sec.3800,Lab.C.) � P❑olicy Na �� � � � ��Company � FOR APPtICANT TO FILL IN JOB Certified copy is hereby fvrnished. New Residential Bldgs.8 Pools EACH NO. FEE AO�RE55 � � Certified copy is filed with the couNy building inspec- 1&2-Fomily,Sq.Ft � — $ LOCALITY . .tion departmeni. Multi-family Sq.Ft. — 'NEAREST ' . - - CRO55 ST. . � Resideniial5wimmingPools OWNEROR ,� Daie Applicanl FIRMNAME � - � � CERTIFICATE OF EXEMPTION'FROM WORKERS' � Outleis:Rec_Light_Sw._ �''ti°��� � COMPENSATION INSURANCE� - aooae55 (This section need not he completed lf fhe work invol�ed by Firsi 20 fhe permif is for one hundred dollars($100)or less.) To1al No. Additionpl CITY Tel.No. I certify ihai in the performance of the work for which ihis PLP.N CHECK � erm�t�s issued,I sholl not em lo an n7PucaNi p p y y person in pny monner so as to become subjecf to Ihe Workers'Compensation Lows. LigMing Fixtures First 20 ADDRESS � Total No. Additionol CITY Tel.No. Date App!icani Fixed Applionces tJot Over 7 HP PERMI7 NOTICE�'TO APPLICANTi If, ofter making this Cer!ifimte of APPUCANT , Ezempfion, �you should become subject to 1he Workers' Rpnge_Heater._D.W.— Compensotion provisions of the Lobor Code,you must forth- Oven _Dryer _W.M._ ADDRESS . with comply with such provisions or ihis permit shali 6e Top _FAU —W.H.— deemed revoked. CITY Tel.No. . LICENSED CONTRACTORS DECLARATION � � Hood _Fan _Ofher— Disp. _Room Air Cond. — UCENSE OR C'lass. I hereby affirm Ihat I am licensed under provisions of Chapter�9 REG.NUMBER commencin with Section 7000 of Division 3 of the Business �' ( 9 � Power Apparatus&Large Applionces DISTRICT NO. PROCESSED BY �, qnd Professions Cede,and my li<ense is in full force and effect. . � � � Size&Type HP,KN/,KVA,-or KVAR V� � License Num6er � � Lic.Class Up to 1 Ind. FINAL � " � Over t to 10 Ind. DATE � � Confracfor � -D'ate '" � �`' ' VALIDATION � ❑ - Over 10 to 50 Incl. FINAL � I om exempt under Sec. Over 50 to 100 Inc BY s( �, B.BP.C.for ihis reason � Over 100 � Date: Services,Swbd.,MCC&Panelboards a � 0-200 Amp.Under 500 V � � � Signature 201-1000 Amp.Under 600 V �" � ' � ' � ' - � -- Over 1000 Amp.or Over 60D V Exemption for Reg.Maini.Elect. SINGIE FAMILY � Temp.Power Pole 8 Appurtenances � HOME OWNER-BUILDER�ECLARATION Sign wilh One Branch Circuii I hereby affirm tha�I am exempt from ihe Contracfor's License Addifional Siqn Branch Circuits ' Law�for the following reason (Se<tion 7031.5, Bosiness and .Professions Code): - ' .� I,as owner of ihe property,will da ihe work ond the Misc.Conduits 8 Conductors structure is not in�ended or offered for sale (Section Other(See Complete Fee Schedule)_ , 7044;-Business and G�bfess�ions Code).�� - � � �- � ' � CONSTRUCTIONLENDING�AGENCY " � �� - , � I hereby affirm thaf there is a mnsirucfion lending ogency for � �� fhe performance of the work for which fhis permif is issued PERMIT FEE (Sub-iofal) . x ' �. a .. . (Sec.3097,C1�.C.J. �,. � � - PLAN CHECKING PEE � � •� • � .� Lender's Name � . � ' � ' � � � PERMIT ISSUING FEE " ' � " -�� � Lender's Address I certify that I have read this opplication and state thot the TOTAL FEE above informption is correct.I agree 10 mmply with oli County ordinances and State laws regulating Eledriml wiring,ond hereby aufhorize representotives of this Couniy fo enter upon . the above-mentioned property for inspection purposes. SEE REVERSE fOR EXPLANATORY LRNGUAGE �SignaWre of Permittee Dote ' . , .: .,.�..o. � ..� , ir 3h1 .. . ., ' . . .� _ . ,.. � . . ' . .. . . � ... . 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