HomeMy WebLinkAbout1155 SOUTH DIAMOND BAR BLVD (83) WORKERS'COlNPENSATION DECLARATION �A6�cw+a:e> APPL1CATtON �OR ELECTRICAL PERMIT �
I hereby offirm tha�I have a tertifi ate of consent to self ce-eca�
insure,or a cerfifimre of Workers'Compensation Insurance, COUNTt C�p LC35 ANGELES DEPT.OF PUBLIC WOI2KS � � �
ai o certi.fyed wpy thereof(Sec 3800,Lab.C.) , . ,�, , . � - � � .-. - �--��—���
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Polic 'K1o.�Coman -�'���� r�'%�'+� FORAPPLICANTTOFILLIN, � M1JOB
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�Certified copy is hereby fomished. New Residential Bldgs.&Poo�s EACH NO� ��FeE� � A��Re55 �{.� Y'/�f C�`t/�' f.'�y'�'�� ��---
�Cenified copy is filed with the wunty build�ng inspec- I&2-Family,Sq.F. _. � — $ LOCALITY
... .. . .,......
� -7ion department. Multi-family Sq.ft. NEaRES` � ��p�;;y
��,:� " -� Residentiol Swimming Pools Qy,�N QE SQg � ��
Date%��. `��Apphcant �,- �.ss�"-�--- �J"i.,"2^, '� -
t�+ FIRM NAME �'' � ��L
CERTIFICATE OF EXEMPTION FROM WORKERS' MAIL
� COMPENSATION INSURANCE O��lets:Rec�_.LigM�Sw._..._ �;�..l - N
AODRESS 1 P
Firs�20
(This secTion need not be completed if fbe work Involved by Totol No. Additionpl ��TY f-%(f1�'�ii!'.r„� (i�Tel.No.
fbe permit is for one hundred dollars(5100�or less.) pLAN CHECK
I certify thot In the performpnce of the work for which ihis ppPilCnNi �r�
permit is issued,I shall not employ any person in any manner
...._. ...._..,.....,,.a„,..-,_.r., . . _....
so as to become subject fo the Workers'Compensation Laws. �ighting Fixtures First 20 � AODRESS
_...
� Additional ...... ._.._.., ,...,,....::..�..,:.--.�_:......�
Torol No. � GTY � Tel.No. ��--',
Date .Applicont ....__..,�.._.--,,... . .. ...,.._.w,,.,..,,.:_...:..:.,,.._:._...-�z_....
Fixed Applioncas Not Over 1 HP PERMIT
NOTICE TO APP�ICANT: If, after making this Cenificate of ppp!iCAiION ai.l� ?I,i �.�y��•,.'4.<
Exemption, you should become subject to the Workers' Range— Hea�er—D.W. _ -
Compensotion provislons of fhe Labor Code,you musf forth- Oven �Dryer --W.M._ ADDRESS '-.'�M(' �.��;�/�%���j �����j�
with comply �th such provisions or this perm�t sholl be 7ap _FAU —W.H.— J
wi --%" '
GTY � �'�.fL C?,E��. -� Tel.No.�J tf!('�`'��:
deemed revoked. „ ,,, _.., ... � Hood —Fan —Other__,_ �"''�F�`''��
IICENSED CONTRACiORS DECLARATION� � . LICENSE OR
Oisp. _Room Air Cond. — REG.NUMBER� ` ,P� Clpss. C.'Yf
I hereby affirm that I om licensed under provisions of Chopter 9 � �
(commencing with Section 7000)of Division 3 of the 8usiness power Apparotus&Large Appliances DISTRICT NO. � PROCESSED BY a
ond Professians Code,and my license is in full force ond effect. `Q/+
` Size&Type HP,KW,KVA,or KVAR O
Llcense Number 'a�i/�`!.� Lic Class �"�� Up to i Incl. FINAL
�'- '�i j'_ Over i to 10 Ind. DATE � �
Confractor&-:�-�£�1�`"-��1.�: Date -2 Z.'�D VALIDATION �
O - ' Over 10 ro 50 Incl. F�NA� �
I am exempt under Sec. �Over 50+0 100 Inc. BY w
B.&P.G.for this�eason ,,.. .,„,.,,„ Over 100 - 0.
_...,.
� Services,Swbd.,MCC&Panelboords � r z
� "'�O�e' 0-200 Amp.Under 600 V "-
Signature '^$"�'^'"t' 201,100p Amp.Under 600 V
❑ Over 1000 Amp.or Over 600 V
Exempiion for Reg.Mainf.Eled.
- SINGLE FAMI�Y Tem Power Pole&A urtenonces
HOME OWNER-BUILDER�ECLARATION Sign with One Branch CPcui� 7� _.v%�`� f i�,
I hereby affirm thot I am exempt from ihe Contrador's License Additional Si n Branch Circuits
Law for the following reason(Section 7031.5, Business and 9 �re '°. � � 'C
Professions Codej:
Misa Conduifs&Canductors � � @ G 0.G�'
❑I,as owner of fhe property,will do ihe work and the _
structure is not in�ended or offered for sale(Section 7044, Other(See Complete Fee Schedule)._ ► ,, _, - v ,'�?
. .. „� �:;:..
Bus�mess and Professions Code). �-���-��"��"- �'�""�
CONSTRUCTION LENDING AGENCY - "' �"-"�""'-" ""�''�- I L G�.�i`S E;
I hereby affirm that there is o consiruction lending agency for
-.,:..-.'..:.�.:::-��
ihe performance of the work for which ihis permit is issued PERMIT fEE (Sub-Total) S
(Sec 3097,Civ.C.�.
PLAN CHECKING FEE
Lender's Name ......-..........m.-ws«�......:..,r_.:,:�.•s::.:.���:,';.tFX� .
. PERMIT iSSUING FEE 'Q ,�,�J
Lender's Address �� . �. --.�-- •�.•-4.��-:. -.���.�+�+� . .
� I<errify thcyt 1 have read fhis applicntion ond sta�e rhat fhe T�TA�FEE ,�� .,�S,�/
above information is correct I agree�o romply with all Coun�y . �
ordinonces and State laws�egulating Electrical w ring, and . . �.
i
hereby authorize p y p � . �� - . . .._. . ... . .� `� � � ' '
re resenfotives of ihis Counf io enler u on • --�• �- �` '�'�' �
._. -. . ... . ........... .._... ,_ ...._ :
the above-menfioned propeny for inspetfion purpose9.� � - , SEf REVE'RSE F�R EX�IANATORY�LANGUAGE
/% �
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.i�ii-x�3c�7. ..yi'Y`^�',.�.+._. f�'�� .: .� ,�� .
._/ ignature of PerniNtee Date ,. - . . . . .' _„ . �5.
� .:, .
� - APFROVALS �M��_� DATE � �p �SPECTOR'S � L?WNE�I-k3Uil.P3E�OECLAR14Yit7N
. ! SIGNATURE � -
YEMP.FO`NER POLE � � �
I fiere6y af9lrm 2hat f am ezanspt fram the Contracfw's
UNDERSLP.�WCRK ���-' � "' '� - LlcsnsmLav:fartl-�afoViowingreason(Seciion703L5,9usiness
ROUGFiCONDUIT � . andProfessiorsCode):Rnycityoreountyu�hionreqmresapeimit
+ ro aonstruct,a{iar,improve,dzmoNSY,ai tepair any 3trucYurs,
� WIRING - ± priorioitsissuanoe,aiscrequlresi.heappficanfforsuchpermitPo
�---- � � � /ile 2 srgned siatement thai ha rs licensed pursuanf to the provi-
i���7���$ ____.___� Sio7%5 Of ifiE ContlBL'.ut'.s!rCdtSB LaW jCnnpi¢�9(Comm¢nCing
�P�QwER iaUTHORIZE� �G � „���' � - wiin Section 7000j ot qivisior 3 as the 6asrness and Grofessior,s
U7tLISYCO.N071FIED � � wde)orthathaisexerrpittere/romand,nebasrs�ortheaOegeG
5 cp axemption.,3ny Wolaticr ctSeciion 703i.5 by arty applicant for e
FliVAi. �ne'eE nt:_3roxE � permit sub(ecYs thg app)icant 7c a cNi!penalty of nui mor2 than
- tive hurMreU dollars;$s00}..
NOTES
� . Q-;-as e;r:isar or.he�ro�ert�wifl da ihe ivafk,antl
..e...�.m,�,�__..._ _..,.�a�_...._.._,_.�.._....,„_� .,_..,_�.._ ttsa a[ructurs Is na[;ntanded or offered for sate.
� . ' � � � � � � � ISea 7044.Busfiess and Professlors Code: 7he�anPraciar's
, _.___ - -Liaense Law does no[apply to an owner of properry who buifds ar
�� � .. improvys.hareor�.and wnc does;�ch work nimse7f prcvided that
� . �_,____,�__ ____�_}__�,__v_„� ��y such improvament3 xre not mten�ed or of{ered for�are. ft,
- - � ' �- , �,-however,tne buildinyg or improv�menr is sol6 wrthin ons year�l
___ _ ________ ,�,__ � ^__^ _� � ��comp�etion,:hecivner-builderwiBhave?heburd�nofAroviagthai
' ' � �� .. . Fie ilyd nct Wifd o;imp�ovs�for�the purpose af sale.)
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.e�.-:_�_�___.�...n.�..�__.. ------- 8&P C;.for Yh'r�r�asort �
+
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