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HomeMy WebLinkAbout1155 SOUTH DIAMOND BAR BLVD (142) WORKERS'COMPENSATION DECLARATION 7hA663 70i8t APPLlCATIOIV FOR ELECTRICAL PERMIY n I hereb,x affirm that I have a ceitificate of consent,�o.self �E-8o6G � . .. ._ ,. .... , ., . .. . ,... �nsure,o�o ce��ifimte of Workers'Compensar on Insurance. � � COUNTY OF LOS ANGELE$ BUILDING�/C�ILJ SAFETY� Gr o<er��f�a'}d�co�py�t��he-r7e�of(Sec.3800,Lo} .1 � �� � � ' � ��•�� P❑olicy No.�Company ��}� �d'�"^� FOR APPIICANT TO Plll IN '.. , JOB ` � . .. . . Certified copy is hereby fumished. New Residential Bldgs.&Pools EACH NO. FEE ADDRESS `{� ', � Certified copy is filed wi!h the coun!y ouilding inspec- 1 8 2-family,Sq.Ft. � = S IOCALITY � . tion department. Multi-fomily Sq.Ft. NEAREST { ��p y�� ResideNial Swimming Gools OWNER OR ���tel_r�S,6,_fG_F-Applicanr_ �,(��'r' K-3-�f'i�� . � I FIRM NAME j U CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec_Light_Sw._� r"�A�� COMPENSATION INSURANCE � I aooaess First 20 (This secfion need not he completed if 1he work invoived by TO1a��o qdd���onal CITY Tel.No. "` . the permit is for one hundred dollars(f1D0)or less.) P�AN CHECK � I certify thal in ihe performance of the work for which ihis APPLICANT 7r � S/ perml�is issued.I shall not employ ony person in any manner _� so as lo become subject to the Workers'Compensdfion Laws. Liqhting Fixtures Firsi 20 .4DDRE55 �.� � v '�,�' ��'�� � _a �� ToYal No. Additional CITY •�;el.No.' Dote - __ . .,....... .��'`S'.�.. . Fixed Appliances Not Over 1 HP PERMIT NOTICE TO APPLICANT� If, after making this Certificate of APPIICANT c. -f�f Exemption, you should become su6jecf to the Workers' Range_Heaier_�.W.— . . . . �ompensation provisions of�he Labor Code,yoo must forth- Oven _Dryer _W.M.— ADDRESS �Niih wmply with such provisions or this permit sholi be Top _FAU —W.H.— - " leemed revoked. Hood _fan _Other_ CITV Tel.No. LICENSED CONTRACTORS DECLARATION LICENSE OR �'- :hereby affirm tha�I am licensed under provisions of Chapter 9 Disp. —Room Air Cand. — REG.NUMBER � F f�L/a Class.�' r commencing with Section 7000)of Division 3 of the Business power Apparatus 8 Large Appliances DISTRICT NO. PROCESSED SY p. nd Professions Code,and my license is in full force and effe<L �a � � .t, �/ ,� ��J� Size&Type HP,KW,KVA,or KVAR �� �cense Number '7��`T��� lic.Clpss�La1— Up to 1 Ind. FINAL O. � � Over i to 10 Ind. DA� VALIDATION N onirocror�'�d�� ����� Date �^��� �. Over 10 to 50 ind. 7 FINAL l.3sJ I om ezempf under Sec. Over 50 to 100 Inc. _ BY N B.&P.C.for this reason Over IDO . Z Date: Servires,Swbd.,MCC&Panelboards � 0-200 Amp.Under 600 V Signarure 201-1000 Amp.Under 600 V � Over 1000 Amp.or Over 600 V Exemptlon for Reg.MoinL Elect. SINGLE FAMILV Temp.Power Pole&Appurtenances � � HOME OWNER-BUILDER DECLARATION Sign with One Branch Cirtuit � ereby offirm that I am exempt from ihe Caniractor's License qdditional Sign 8ranch Circuits �� .✓for the following reason(Section 7031.5, Business and 'fessions Code): � nn�s�.co�d��fs a ce„a��,ors (� �5 3 9,5 A 1 I,os owner of ihe property,will do the work and the ' � U , slrutlure is not infended or offered for sale (Section Ofher(See Complete Fee$chedule)_ , I 5 ��a�o • �'� 7044,8usiness ond Professions Code). 1.��} � CONSTRUCTION LENDING AGENCY � V, �� •!�5'`5 O �re6y affirm ihat there is a construdion lending ogency for �� - �-- y m m 2�J,5�� performance of the work for which this permit is issued PERMIT FEE (Sub-Total) ' .� -c.3097,Civ.C.). � PLAN CHECKING FEE O�,��"H 7 ider's Name �� � �� �'� PERMIT ISSVING FEE �� ider's Address �� =rtify iha�I hove read this appli<ation and state ihal the TOTAL FEE �ve informotion is correct.I agree to comply w�ih oll Counry � � - � �� � '� � ' � � � inonces and State laws regulating Elecrrical wiring,ond eby authorize representorives of this Counry to eMer upon �above-mentioned p�operty for inspection purposes. 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