HomeMy WebLinkAbout1155 SOUTH DIAMOND BAR BLVD (150) — ...�....._. ,.., ..,.,.n�,.,... ,—�._ ..., . �_.a...,.,. :>�.�si,z�unx�.,v..+�s�,�s.>�x.s;:.��:+�,�se�::_,»�n�w:�.�a��.-z,�m.�r..�..�.,- _. -'.aars�-p:.drM,..-�.. .
WORKERS'COMPENSA710N DECLARATION 76A6d3 70�81
I hereby a,f��,�m �ha, � ha�e a certifimie ot<o�5e,,o_=e�f ,� -E-�� --- -� � APPtiCATION.FOR ELECTRiCAL PERMIT . ,
..__. _. .. _ ._. _.
_._ --
, Insure,or a cerrfimte of Workers'Compensatlon-Ins�ance, �QUNTY OF LO$AN�oELE$. .� ��' ��� ��IL'�ING 1�11�SAFETY
- or a rertif�ed copy'hereof(Sec.3800,Lab C.? -
.. . . .
'. Pol cy No��:'." '." : 'Compony�.. � ��..:� • .. : . FOR APPLICANT TO kILC.M"....."". . '..'.'.....".. JOB '-
� Cer�ified ropy is hereby furnished. New Residentiol Bldgs.&Poo�s EACH NO FEE ADDRESS
� Certified copy is filed with the county building inspec- 1&2-Fomily,Sq.Fi. $ — 5 IOCAUTY � '
rion depoftment. � - ' - Mulii-fomily Sq.Ft. — NEARE57
��=j� ' - . . � Residenfiol Swimming Pools CROSS ST . �
Dote � Applimn — _ „ - OWNER OR '��
� Y� ' l '/ FIRM NAME. �
CER71fiCATE OF EXEMPTION FROM WORKERS' Outlets:Rec_Lighl�5w.__ �'�'A�� , "'� - -�� '�� � �-
' COMPENSATION INSURANCE �- � � � ADDRE55� ' �
�. (This section need noT 6e complefed if ihe work Involyed by First 20 , --. ._.. .
� � the permit is for one hundrad dollars(5100)or less.) Tora1 NO� Additional CITY!:� , . . � Tel.No... -�- +�
i certify tFot in the performonce of the work fo�which th�s PLAN CHECK „�µR,� � " ' "'
- APPLICANT
permit is issued,I sholl not employ any person in ony monner � , � . _
so as ta became subject to the Workers'Compensotion Laws. lighting Fixtures First 20 ADDRESS �--•-�-�^�-
� To�al No. Additional W � - -_..__._
� Dare Applicont CITY .,...-- Tel.No. �
Fixed Appliances No�Over 1 HP PERMIT
� NOTICf TO APPLICANT: If, after making ihis Certificate Of ' APp���p,NT ,�'� .'~. . . T
' Exemption, you should berome su6iect �o the Workers' Ronge_Heater_D.W,. �
Compensotion provisions of ihe Labor Code,you must forlh- Oven _Dryer —W.M.___. ADDRESS �.; :�'�
with comply with such provisions or this permit shall be Top —FAU —W.H._ y
deemed revoked. Hood _ CITY -: � - Tel.No.-.
LICENSED CONTRACTORS DECLARATION �Fan Other__ ., . , : .V
' Ois _Room Air Cond. — uCENSE OR- ' ., �
I hereby pffirm that I am licensed under provisions of Chapier 9 P' REG.NUMBE&P�;."�� Class: Q
(commenc ng wirh Section 7000)04 Div s on 3 of the Business power Apparp!us&lorge Appliances DISTRICT NO - PROCESSED 8Y �J
�, and Profess ons Code,and my license is in fu�l force and effect.
Size&iype HP,KW,KVA,or KVAR �I ' �
' License Number �� �'=..�__�Lia Class�-'. ... . . . Up to 1 In<I. FINAL - � - . � �+-
� � - ��� Oyer 1 to 10 Ind. DATE }
Contractor- . � . � ',. � •:- Date � ''. - �.% . VALIDATION
. _._, . ,.,....._..,......... Over IO fo 50 fnd . ... �
❑ FINAL
I am exempt under Sec. Over 50�0 100 Inc. 8Y 0
' B.BP.C.for ihis reason Over 100 a-
Date: Services,Swbd.,MCC 8 Panelboards , �„�j�
0-200 Amp.Under 600 V r
- Signoture 207-1000 Amp.Under 600 V
� ❑ _�� Over 1'000 Amp.or Over 600 V
E.emption for Reg.Moint.Elect. i
� SINGLE FAMIIY Temp.Power Pole 8 Appurtenonces
HOME OWNER-BUILDER DECLARATION . Sign with One Brqnch Circoit
I here6y affirm ihat I om ezempt from the Contractor's License qddilionol Sign 8ronch Ciicuil5
Law for Ihe following reason{Section 7031.5, Business and
� Professions Code): -
� ❑ I,os owner of ihe property,will do ihe work and ihe Misc.Conduits&Conductors
sfructore is noi intended or offered for sole(Section O�her(See Complete Fee Schedolel— ► - ' ' �� � -
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY .
I hereby afflrm tha�rhere is a<onstrudion lending agenty for . . ,. ' � " ^ -
� , the performance af the work for.w,hich.this permlt is issued pERMIT FEE (5u6-Totaly ' , . . , �
(Sec 3097,Civ.C.). , ��
. PLAN CHECKING FEE
Lender's Nome
��� ��� '��- PERMIT ISSUING FEE "
Lender's Address
�cerri{y tha�I hove read fiis applicalion ond state thot the TOTAL FEE � �
above informatio��s<orrecf.f agree ro mmply witfi all Counly �� � -. � �•-,..�----.� .. , _. . .. . , ,
ordinonces and Stote�aws_regulating Eleclrical wiring,and
h�reby authorize representolives of this County fo enter upon
.dhe above-me'n!ioned property tor inspection purposeg.
. � ;�,; .� - � SEE REVERSE FOR EXPLANATORY.LANGUAGE _
./. .�,.j.. .. ... /�r.��� .,'A � .. ,.. . .. ...... .
����;S g at re cf P +t e Da e �� -