HomeMy WebLinkAbout1155 SOUTH DIAMOND BAR BLVD (125) vvVHKtRS'COMPENSATION DECiARATION ��`� ��'87 APPLICATION FOR ELECTRICAL PERMiT
I he�eby affirm thor I have a cerfificate of consent w self �E-806G �
o�ernt��o�e o+wo�kers'compe�sarian��sora�ce, COUNTY OF LOS ANGELES BLIIDING AND SAFETY.....
- o�orcerrified mpy rhereof(Sec 3800,Lab.C.) . _. - �.. � . ;_-
_ . ... . . �., .
� P�ol'icy No. Company . .FOR APPIICANT TO FILL IN J08 �
ADDkE55 �".: ,:� ,1.. .'y�.
� Cerlified copy is here6y 4urmshed. New Residential Bldgs.&Poals E.nCH NO. FEE , . ''���� '
� Certified<o s filed wirh rhe munt build�n ec- 1 8 2-Pamily,Sq.Ft $ — 3 LOCALITY
, rian depariment. Y 9��SP Multi-family Sq.F�, NEARESt
CROSS 5T.
� . Dore Apphmnt Residentiol Swimmmg Pools �RM NAME
� CERTIFICATE OF EXEMPTION FROM WORKERS" putleh:Rec_Light�5w..._ MA�� � �
COMPENSATIpN INSURANCE ADDRESS ;-' ,� - . _
.. �; , :'
First 20 -- v` - . -
. �(Tbis secfion need nof be complefad if fhe work involved by Totol No. CITY .,,.,. ., _� ��; . • Te1.�No.
fhe permit is for one hundred dollars(S100J or lesz.) Addi�ionai .��.
� � I cerr�fy rhor in ihe performance of rhe work for which fhis I j PIAN CNECK�
permlt is issued,1 shoil not employ ony person in any manner I AaPUCANT
sa os ro become subjeci Io iheWorkers'Compensalion Laws. LigMing Fixiures Flrst 20 A�DRESS
� Toto!No. Additional
' CI7Y 7e1.No.
Dare�`���'�..• ��Applicanf �'^v<;(�� E'N.-+':.Y�•:.., '"�FixedAppliancesNo�Over1HP PERMIi
NOTICE TO APPLICAN7: If, af�er mpking rhis Certiiimte of � qpp���,pNT . l':� .,;.�,;.� ... . j�:�.'.
Exemp�ion, you should be<ome subject fo the Workers' Ronqe_Heorer_D.W._ - '�
Compensa�ian p.ovis�ons of fhe Labor Code,you musr fo�th- Oven �Dryef —W.M.� ADDRE55 - , � ,� -:,..- �,
ilh comply wifh such provisions or Ihis permit shall 6e Top —FAU �W.H.— �' � ' �'� ,
deemed revoked. Haod _Fan �Other� QTY .•:,, .,r, Tel.No.�`.`,"y,�,,,..,,,,..
IICENSED CONTRACTORS DECLARATION uCENSE OR �" � Q
I hereby affirm fhat I am licensed under provisions af Chopter 9 �'sP� —Room Air Cond. � REG.NUMBER ���"=' Class. v.
Icommencinq wirh Section 700d1 of Division 3 of the Business power�Apparat�s&Large Applionces DISTRICT NO. PROCESSED BY C J
and Professions Code.and mv�icense is in full force and effect. �
� Size&Type HP,KW,KVA,or KVAR -�
License Number �%" +��`��"- Lic.Closs f ' d�`� � "" --� V-
Up fo 1 IncL FINAL
- Over 1 to 10 Incl. DATE VAlIDA710N }
Contractor f�'i':;:'_i :cY''-6�:i�Dote ^'r .. .,^"' �
❑ �` '��`'� Over 70 to 50 Incl. FINAL
I om exempi under Sec. Ove�50 to 10p Inc BY �
8.8P.C.for�his reason �Ve��� a
Dore: Services,Swbd.,MCC 8 Panelbaards ► �
� . 0-200 Amp.Undsr 600 V
Sg�a�ure 207-1000 Amp.Under bOD V
❑ Over I000 Amp.or Over 600 V
Exemption for Reg.Moint EIeU.
� SINGLE FAMILY Temp.Power Pole&Appurrenonces
' HOME OWNER-BUILDER DECLARATION Sign with O�e B�onch Circu�i
I hereby offirm that I am exempr from�he Contra<ior's License Add+��anai Slgn 8ronch Cir<uits � �
Low for�he follawing reason�Senion 7031.5, Business ond
Professions Codel: � � � � •'
❑ I,os owner of+he Misa Condoi�s&Co�duc�ors , ;
property,will do rhe work(nd the p�her See Com lete Fee Schedule ,
s�runure is nor intended or offered for sa�e Se<rion ( P �— �
7044,Business and Professions Code). ���� �- �� -. -
GONSTRUCTION LENDING AGENCY -
.�...,.., , `<<
I hereby atfirm 7hat there is a mnst.uUion lending agency for � � �
rhe pe�4ormance of rhe work for whi<h this permit is issued PEf2Mf7 FEE (Sub-Total)
(Sec 3097,Gv.C.1.
� � � PLAN CHECKING FEE
Lender's Nome
� PERMI7 ISSUING FEE
Lender's Address �
i cer+�fy�ho+I hove read ihis opplica�ion ond sto�e rhat the TOTAt FfE - �
obove informo+�on is correcr.I agree�o wmply wirh all County
ordinonces ond S�ate lows regu�afing Electrlcal w ring,pnd
here6y authorize represeniotives of thls Cou�ry ro enrer upan - �
�he o6a�e-mennoned propeny far�inspecnon pu.pases. SEE REVERSE FOR EXPLANATORY LANGUAGE '
r�;,:�, ..G i:.. s,i`T.�"s•"aLr*t:. ���'4� _..
Signotu�e'cf Permillee �nte - � . - �