HomeMy WebLinkAbout1155 SOUTH DIAMOND BAR BLVD (146) - . WORKERS'COMPENSAT!ON DECLARATION 76A663 10�81 /� � ' � �- � -�- - � - �� -�--- --�--
� I hereby affirm !hot I have a certificate of conseN to self CE-806G � - MPPLICATION FOR EL�CTRICAL PERNIIfi��- � -� �
ins�re,o�a ce�tiflmte of wo�kers'Compensario�I�wronce, COUNTY OF LO$ANGElES BUILDING AND SAFETY"�°�� ��^W"
or o certified copy ihereof(Sec.3800,Lab.C.1 �
. .. .... ..... . ..... ,.. _.
• P❑ol�icy No. Company FOR APPLICANT 70 FILL IN JOB /; , , -' � .
Cerniied copy is hereby furnished. New Residential Bldgs.&Pools EACH NO. FEE
ADDRESS ""�r 1 ,
� Certiiied copy is filed with the coonty 6uilding inspec- � 8 2-Family,$q.Fr. S —�S IOCALITY . �,,;.
. tion deportmenf. Multi-fpmiiy Sq.Ft. — NEAREST -
� CRO55 5T. � '�
Residentiol Swimming Pools �
Dafe Applicon� OWNER OR 1,. ;�, ,^
f_ FIRM NAM%� �.'i� _
� �; r-,_ RTIFICATE OF EXEMPT16N FROM WORKERS' � - I .Mqlt . � .
..� .:,:� O�tlefs:Rec�_Light_Sw.,.i �Y,��,� .
COMPENSATION INSURANCE ADDRESS " �•�- �-
(This secfion need nof be compleTed if ihe work involved by j First 20 �
, fhe permit is for one hundred dollors(S1D0)or less.) Total No. � Additionol QTY� . : , Tel.No. �� ,-f,��
I certify that in the performante of the work for which thls PLAN CHECK -
'permit is iswed,I sholl not employ any person in ony manne� i APPLICANT
so as to be<ome subject to rhe Warkers'Comp.ensation LbwS. ��gh�ing Fixrures Firs;20 ADDRE55
" �.-1 �:• �. � ;� Additional
�;..; ;�,. �: '� ' .; .�,. , •. ._.. . . .Total No. CITY Tel.No.
�ote' ' ' ' oppli<anf ' ` � Fixed Appliances Noi Over I HP PERMIT
NOTICE TO APPLICANT: If, ofter moking this�Certificdte of- APPUCANT-.. :/.',
" Exemption, you should become subject to the Workers' Range—Heater_D.W. _
Compensation provisions of rhe Lobor Code,you musl forth- Oven _Dryer _W.M.— ADDRESS
with mmply with such provisions or ihis permit sholl be Top _PAU ._W.H.—
daemed revoked. CITY Tel.No. 0.
�, LICENSED CONTRACTORS�ECIARATION Hood _Fon _O�her_
� Dis _Room Air Cond — LICENSE OR Q
, I hereby affirm that I om licensed under provisions of Chopter 9 P� REG.NUMBER �. ' ' ' Class.;`��,'�, �
(commencing wi�h Section 7p00)of Division 3 of the Business power Apparatus 8 Large Applionces DISTRICT NO. PROCESSED BY W
and Professions Code,and my license is in fuli force and effect. I :..f
Size 8 Type HP,KW,KVA,or KVAR Li
License Num6er Y" � ` Lic.Class"" ����' FWAL 7'�
;�„_... :,-, _. _ Up to 1 Inci. DATE �
�'r.,��� a 7 - , . . Over I to 10 Ind. VAL�DATlON ,�
Confroclor�T Dofe ' Over 10 ro SO�nd. O
❑ FINAL
I am exempf under Sec Over 50 to 100 Inc 8Y Ll
B.&P.C.for this reason Over 100 �
�ate: Services,Swbd.,MCC&Panelboords , F�
0-200 Amp.Under 600 V
Signature 201-1000 Amp.l)nder 600 V
� . ❑ - - � Over 1000 Amp.or Over 600 V
Exemption for Reg.Mainf.Eleci.
� SINGLE FAMILY iemp.Power Pole 8 Apportenances
HOME OWNER-BUILDER DECLARATION - Sign with One Branch Circuit
I hereby affirm thot I c m exempt from the Contractor's License qdditionol Sign Bronch Cirwits
Law for the following reason(Section 7031.5, 8usiness and
Professions Code): .
❑ I,os owner of the propeny,will do the work pnd the Misc.Conduits&Condudo�s - "�� � - =/-
siruc�ure is not intended or of{ered for sale(Section Other(See Complere Fee Schedule)— , . e,c a a�
� 7044,Business and Professions CodeJ. �
CONSTRUCTIONlENDING AGENCY °'�'�"���s "' '
I here6y affirm�hat ihere is o consiruction lending agency for ,� �:�, ;
the performance of ihe work for which this permit is issued pERMIT FEE (Sub-iotal} �� - -��� -"
(Sec 3097.Civ.C.). � ,
' PLAN CHECKING FEE ������� �" � ��
' lender's Name
PERMIT ISSUING FEE „"�.
Lender's Address
, I certify ihot 1 hove read�his application ond state that the TOTAL FEE
a6ove informotion Is mrrect I ogree!o comply with oll Couny
ord;nances and Stafe lows regulating Eleciricol.wiring,ond -
� nereJhy ayihorize represemotives ofi`thi5 County to_=n�er upon �
� {he dboye-me�tlqned�property foqrinspectian purposes.
� SEE REVERSE FOR EXPLANATORY LANGUAGE
Signoture ef Permi�ree � Dote