HomeMy WebLinkAbout1155 SOUTH DIAMOND BAR BLVD (128) ; . .. ...,
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WORKERS'COMPENSATION DECLARATION 2e-oaworwa%5� APPLiCATI�N FOR ELE�tRICAL� PERMIT �
I hereby aff�rm rhar I hove a certificare of conseni ro self ��t� . ,
insure,br a cerrfim�e of Workers'Compensation Insu�ance, COUNTY OF-LOS ANGELES DEPT OF PUBLIC WOf1K5
or a cerr{ied coPY�hereof(Sec.3800 Lab C.1 � �,., ':y,�`.�,����.,,: -.. .,,��.�..,±�:� ,�,, .�^F„�.
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'.. Pol cy Na.": ...• �Company ..� '- .... '' ..,. �. ..._. ..FOR APPLICAN7,10,FILL IN. _ .._. r...,....,.. JOB � '
� �Cerr fied copy is hereby furnisheo. � � New Residential Bldgs.&Pools EACH NO, FEE AD�RE55 7� � ,'1. ✓ '" L..�
�Ceriified mpy is filed wi!h fhe counfy 6uilding inspe<- 1&2-Family,Sq.Fi. $ — S LOCALITY
tion depariment. Mul�i-family Sq.Fr. — NEARES'
CROSS Si. �;':/+,7
� Residenlial Swimming Pools OWNER OR
Date''° - Applicont - � FIRM hA�J�E
CERTIFICATE�OF EXEMPTION FROM WORKERS' Outlets:Rec_LigM_Sw._ nnAiL _ � '
COMPENSATION INSURANCE n�DRe55
First 20
(This sec�ion need not be completed if fhe work involved by Toral No. Addirional CI7Y , - Tel.No.
,.,:.:-:�r.�,.'.L: ,::..�.a.
fhe permiT is for one hundred dollars(S1D0)or less.) PLAN CHECK
I certiFy that in ihe pertormonce of 7he work for which 7his aPP�ICANi "'""""�'""'~
....:.��:�:�
permil is issued,I shall not employ any person in pny manne� � ' - ��" � �� '� ��
so as ro 6ecome su6ject to the Warkers'Compensation Laws. Lighiing Fixtures First 20 ADDRESS�,
Additional
Date Applican+ , yW Total No. CITY „� Tel.No.
NOTICE TO��APPLICANT: If, ofter making ihis C r±ifimte of�� FixedApplipnces NolO�er 1 HP pERnnli
Exemprion, you should become subject to the Workers' Range—_ Heafer—D.W. — AFPUCA710N�.�
Compensation pravisions of the Labor Code,you must forih- Oven _ Dryer —W.M.— ADDRE55 � .
. wuh comply wnh s�ch provislons or this permlf shall be iop —FAU —W.H.— QTV '�Tel.No."�/�;^���
deemed revoked. Hood �Fan —Other_ �"��"�-` ���:� - � : � �
LICENSED CONTRACTORS�DECLARlTrCSN������� � uCENSE OR �
Disp. .�Room Air Cond. _ REG.NUMBER ' ''7_%•� Class. '
.I hereby affirm thai I am licensed under provisions of Chopter 9 a
(tommencing with Secfion 7000j of Drvision 3 of ihe Business Power Apparatus&Large Applionces DISTRICT ND. PROCESSED BY Q
ond 7rofessions Code,and my license is in full force and effect. 1 V
� Size&Type HP,KW,KVA,or KVAR � '
License Number . ��r � L;c Closs Up to 1 Ind. FINAL . J
- .,,..-.--°-.."^`;�'.,�,,.s, Over 1 to 10 Ind. DA7E VALIDATION W
Controctor�� ���� �� � Dafe �_�r_"�—,.__ Over10to501nc1. }
� .� r - FINAL �
I om ezempi under Sec. = ` -�� �" O��er 50 fo lOD Inc. gy Q
- Over 100 .. �
B.BP.C.for this reason . :--_.-,-..:.---. O
� ' Servires,Swbd.,MCC 8 Panelboards , a
__ -• Dote: 0-200 Amp.Under 600 V �
Signature .. 201-lODO Amp.Under 6p0 V �
aOver 1000 Amp.or Over 60D V
Exemption for Reg.Maint Elecr.
SINGLE FAMILY Temp.Power Pole&Appurtenantes
HOME OWNER-BOILDER DEQARAiION
I hereby offirm thai I am exempt from the Contrador's License Sign with One Bronch Ci�cuit � , -.;:r t.
low for ihe following reasbn�;Section 7037.5, Business and Additional Sign Branch Circuih
Professions Code�: . � ' " � ''"�
Misc Canduits 8 Conducrors ' • •'� :�
❑I, os owner of ihe property, will do the ork and Ihe " ' ' ���j�
structure is not infended or offered for sale(Section 7C44. OYher(See Complete Fee Schedule)_ � � x ti� j -
:!-:'
Business and Professions Codej. .-.-.-..-...•.��-����..-x-,<•u � + `
CONSTRUCTION LENDING AGENCY � f i,x C'-.'"��i',
I hereby affirm thot lhere is a consfruction lending agency for -�"""""�""��"
the performanc�of ihe work for which ihis permit is issued PERMIi FEE ;Sub-Toral)
(Sec,3097,Civ.C.). . ,
� PLAN CHECKWG FEE
Lender's Name ..._. _ ........,::....,�....,a�r.,ry�r
� PERMIT ISSUING FEE
Lender's Address . . ._.__..... ...:._:::..:,.�,;.�..: �. �
I certify thql I hpve.read this application ono stote fnat the TOTAL FEE . �� . .t.u,,;,�.-:y�- ,
above information is mrred.I ogree ro comply wdh qll County � �
ordinonces and State lows regula7ing Electrical wving,and .
hereby authorize representotives of�his County to enter uPon _ -.�- <- -� �"���-
_ -..
the above-mentioned property for inspeUion purposes. "'��`"'� �"��� ��-� �� � 1 � � � �
, SEE REVEYtSE"F2S�R"�%PLdNATORY IANGUAGE� .
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.��Signature.of Permdtee .... . ' �..Date � _.` . .,. _..... . ....... . . . .... . .. @s
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