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. SEE REVERSE FOR EXPLANATORY LANGUAGE
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