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Home My WebLink About1164 DIAMOND BAR BLVD (18) WORKERS'COMPENSATIONDECLARATION '76A663 ,o,a, APPLICATION FOR ELECTRICAL PERMIT _ � I hereby affirm tha�I have a certificate of consent to self CE-806G i�svre,or a cerifficate of Workers'Compensoiion Insuronce, COUNTY OF LOS ANGELES � BUILDING AND SAFETY or a certified copy thereof(Sec.3800,Lab.C.) I P❑olicy No. Compony � FOR ARIICAIi�TO Fllt IN� ppDRESS �/ � � y/ � Cerlified copy is hereby furnished. New Residen�iol Bldgs.8 Pools EnCH NO. FEE 1 8�-Famil Ft. E — E LOCAIITY Certified copy is tiled wi�h ihe county building tnspac- Y.59• lion deportmeM. � Mvhi-famity$q.Ft. — NEaREsr (( . ResideMiol Swimming Pools CRO555T. Dote �� " A�pplimnt � . OwNER OR FIRM NAME CERTIfICATE Of EXEMPTION FROM WORKERS' Outlets:Rec_Light_Sw._ �'�� COMPENSATION INSURANCE � /+�DRESS Thit��ctton n��d not b�com lefed if ths work Inrolved 6 first 40 � � P Y Total No. Addilional � CITY.� Tel.No. fhs parmh it fer ene hundr�d dollan(5100)or less.) I certify that in the performante of the work�for which this PLAN CHECK APGLICANT parmi�is issued,I shall not employ ony person in any manner � so as to become z�6ject to ihe Workers'Compensation Lows. Lighting Fixtures First 70 ADDRE55 Toial No. Additional � � CITY � Tel.No. ,si Date Applitant Fixed Appliances Not Over 1 HP PERMIT NOTICE TO APPLICANT: If, ofler moking this Cerlificate of APR,�CANT Exemption, you should become subject lo Ihe Workers' Range_Heoter_D.W._ � Compensotion provisions of the lobor Code,yoo most forih- . Oven�_Dryer _W.M.—� ADDRESS � witfi comply with such_provisions or this permil sholl be Top �FAU —W.H.— deemed revoked. � �-. � � QTY - � Tel.No. � LICENSED CONTRACTORS DECLARATION Hood _Fon _Orher— : - Disp. _Room Air Cond. — I�CENSE OR /G!� ��ass.C� I hereby affirm thal I am licensed under provisions of Chopler 9 RFG.NUMBER O ' (commencing wi�h Sec�ion 7000)oi Divislon 3 01�he Business power ApparaWs 8 Large Appliances . DISTRICT NO. PROCESSED BY } i ond Professions Code,ond my license is in full force and eNect � � - - y ��r � � r y�s Size 8 Type HP.KW,KVA,or KVAR � � I �icense Number 0 Lit.Class / l� Up to 1 Incl. FINAL ` - �rrJLi'L*� Over 1�o IO lncl. DATE S / VALIDATION � � Confrodo ��e�� Over 10 fo 50 Ind. . � V FINAL I am eMemp under Sec. Over 50 ta 100 Inc. BY W B.&P.C.for rhis reason ' ( Services,swbd�nnccs Po�eiboo�d5 �� . �3 0 Z 8 A . ? Dafe: 0-200 Amp.Under 600 V ► � ��:� � • •2 � Signoture � 101-1000 Amp.Under 600 V � �� , -- ❑ Over 1000 Amp.or O�er 600 V I • •2 5.5� E�emption for Reg.Moim.Elect. SINGIE FAMIIY Temp,Power Pole&Appvrtenonces ,�\' '2�5��_'' HOME OWNER•BUIIDER DECtARATION 5�g�w��h One Branth Circuil O�3 O$'B�l I hereby offirm thot I om e.empt from the Confrac�or's License .. Addtional Sign Bronch Circuits � Law fcr fh>felloving recsen(Se:ticn 7031.5,Bosincss ond . � Professions Code): ❑ 1,as owner of the property,will do Ihe work ond the Misc.Conduits 8 Conduclors � - - � slr�c�u�e is not intended or affe�ed for sale(SeUion Other(See Comp�ate Fee Schedule)_ ► 704d,Business and Professionz Code). . CONSTRUCTION LENDING AGENCY - . I hereby affirm that the�e is a constrvt�ion lending agenty for - the periormonce of Ihe work for whith ihis permit is issoed PERMIT FEE � � (Sub-To�ol) �5 Q77 - � _ . -. . (Sec.3097.Civ.C.�. �. - . . �fj�� P4MF�1l�RfN9ffE. . . � ,Q (� . . . . lender's Name (L/1L � - PERMIT ISSUING FEE . . �`j U tender's Address � � � � �' � I ceriiiy ihol I have reod this opplication and state Ihat the TOTAI FEE above inform ion is corr I agree�o tomply wiih all Coony . . � ordinanc d Sta�e I s egolo�ing Eleclrical wiring,and , _ .,. � � , . hereb u�horize�epr eni iives o(�his County�o en�er opon � - . the ave-m ti ne pro erfy for inspettion purposes. � SEE REVERSE FOR EXPIANATORY LANGUAGE .,,�--�� . gn re }Perminee b Dote . � _...------- _. � - 'r' � . . .- i ', ' � ` , • .� i_ � �: � ' � � ', `� � . ' , �- , - . , � :� • . :. • t � ' , i ' _" ti-�. ' ' � � . � . . ., . � , � � _ , r ' � � ' � _ . � .' '. ,X � o � � _. p Z �. $ C x � � ''p .. S u' $ "° • , r � rD.. �1 �j � �l O � m .O ' , . �+' O Ci' Z � A .G . `� . O�i '70 '� p O � . _ �J =n ,N., . � o 0 � p �.. � t ' d . . . .. O �� rl � . � .. � O' �. �' � ' y ' . I� C '. , . 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