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HomeMy WebLinkAbout1122 S DIAMOND BAR BLVD (2) 1 _. .. . .. . . . . . . . . . . .... . �, .. ..... .. ... ..... .. .. . . . . .. . ..... . . .. . . .. . . � � �WORKERS'COMPENSATION�DECLARATION . -� (76A663 �a,B,. �� qp�PL1eATION �FOR�. ELECTRICAL PERMIT � ��.���; I hereby affirm ihat I-have a cartifimte of consent,to.seJf� �I CE-806G . . . � insure,or a cer�ificate of Workers Compensation Insuwnce, � �. � COUNTY OF LOS ANGELES � � BUILDING AND SAFETY�.� �� � � . or a cerhfied copy fhereof(Sec 3800 lab.C�.+1 'I, � . P❑olicy Nowcraai�ti Company ����u����-�-��L� I FOR.APPLICANT TO FILL IN )OB .��r>� �. ��r,��/''� j��r J,I��' . . Certified copy is hereby tum�shed. ���� EAGH NO. FEE ADDRE55 G. ��y,� .d 11 � New Residential Bldgs.&Pools rI LOCAtITY ;1 /'Y1 � ��Certified mpy is filed with the county building insper 1 8 2 Fomily,Sq.Ft. $ — �' tl.S�UI I!J ��.Y � � lion department. - � � I Mulfi family$q.FL � — �NEAREST � 'j ceoss sr. ��f dllC_� c`�1/('_ / Residentipl Swimming Pools OWNER OR �1 /� ✓ ni Date-�'�1!Applicant . .WI L }3C1�1��Jti+l {7 . . F�RM NAME CERTIFICATE OF EXEMPTION OM WORKERS' . -MAIL 1I/_L C_�IH�Y(1CJIICJ LlL�IY �IV�_ � Outlets:Rec_Light_Sw._ 1 � COMPENSATION INSURANCE . First 20 ADDRE55 � � (This secfion need nof be completed IF The work involved by� 7otal No. Additional QTY Tal. .�� ��9 the permit is for one hundred dollars(SI00)ar less.) PfAN CHEC (' n 'I /� y, � 1 cerlify thot in the performance of ihe work for which ihis � � APPLICANT �_L.y��yP(�^� 17r ' J j�� . permit is issued,I shall not employ any person in ony manner � - �so as lo become subject to the Workers'Compensation Laws. ..�� �ighting Fixtures First 20 ADDRESS i��}`�",'�N/ �� C,�u�p.� � : . � � Total No. Additional f� ���� �,� �'��J� . . Date Applicant QTY l Tel.N�. NOTICE TO APPLICANT: If, after makin this Certificate of� ` Fixed Applionces Not Over 1 HP PERMIT Exemption, you should�become-subjecl to tfie Workers' Range_Heater_D.W.� APPLICANT A.C.Ad�er�t�t � �1�(�� � Compensafion proaisions of fhe Labor Code,you must forih- � Oven _�ryer _W.M.— ADDRE55 j785 �Irt'aw ratil�e �u1 EC U�J . � with comply wdh such prov�sions or ihis permit sholl be Top _FqU —W.H.— I - deemed revoked � . " � CITY i��r� Tel.N�� '��,�-�'G LICENSED CONTRACTORS DECI ARATION� Hood _Fan _Other— � . LICENSE OR Disp. —�Room Air Cond. — ���� Class.C- -i here6y affirm fhat I am licensed�under provisions of Chppter 9 REG.NUMBER .(mmmencing with Section 7000)of Division 3 of the Business -' ' power Apparatus.8 Large Appliances DISiRICT NO. PROCESSED BY r i . and Professions Code,and my license is in full force and effect � Iq � /�/�I/ � ' (`,_�� Size&Type HP,KW,KVA,or KVAR� �v a � License Nu ber ~r•r�t Lic Class � Up to 1 Ind. /� � FWAL � � I.' � � ����m Over 1 to 10 Ind. DATE� ^�}' VALIDATION � � � Conirac - � e� '� (J . � � � � Over 10 to 50 Incl. . F- I a xem f under Sec. FINAL P .Over 50 to 100 Inc. BY W � 6.&P .for ihis reason Over 100 n' � � � . � ` Services,Swbd.,MCC&Panel6oards ► � Ddte: f . 0-200 Amp.Under 500 V � ISignoture 201-1000 Amp.Under 600 V Over 1.000 Amp.or Over 600 V �, Exemption for Reg.MainL Elect � � � � � SING�E.fAMILY � '. Temp.P.ower Pole&Appurtenances -'4'`�'���,�'P � � HOME OWNER-BUILDER DECLARATION �� Sign with One Branch Circuit +1 s o t E��'.e Z I hereby of(irm ihat I am exempt from the Contrpctor's License � �aa;�; i�, a, �!,; ;� �� � �iaw Tor ine toiiowing reason(Jection�/U31.5, tlusfness antl """'•"'•�. y ".�'.`..`.."".' Pro(essions Code�: . �� - � ° °'2:�.��V � � " Misc.Conduits&Conductors - �r�n= . � I,as owner of the property,will do the work and fhe � . ,_ . . !ti � structure�is noi intended or offered for saie (Sedion�..��' Other�See Cbmplete Fee Schedule)— � �J � . - 7044,Business and Professions Code). . � �� , (7 j,� {I.-�,(j ;- . CONSTRUCTION IENDING AGENCY � � - I hereby affirm Ihat�there is a construction lending agency for � - ihe performance of the work for whith ihis permii is issued �. ' pERMiT fEE (Sub-Total) y�' L-� . . � . � (Sec 3097,Civ.G.). � . � -�� PLAN CHECKING FEE � � � �ender's Name - '� , ��`. PERMIT ISSUING FEE (� �� � Lender's Address , � I cerlify thai I have read this applimtion and stale Ihnl Ihe . � TOTAL FEE � �',.� - . above information is mrrect.I agree to mmply with all County � . � � ordinances and State laws regulating Elec�riml wiring,and �,,.' � �hereby authorize represeMatives of ihis County b enfer upon . � � lhe above-mentioned property for inspection p�rposes. 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