HomeMy WebLinkAbout1184 DIAMOND BAR (9) WORKGRS'COM1IPENSATIONOECLARA7fON � �6A663 �APPLICATION FOR ELECTRICAL PERMIT - �
� � CE-806G f2�601 .
1 hereny attirm that [ have a certi�icate oi consent to se�f i COUNTY OF LOS ANGELES BUILDING AND SAFETY
insure,or a certificate of Workers'Compensation Insurance,or % � .
a certik ed copy thereof ec.3800,Lab.CJ -
'�9 L�� � ,� f T� P .�( FOR APPLICANT TO FILL IN J08
I v�NYN�`jTGG G1 ComPany'i.k"^!�L'A��l�'�. ADDRESS
. `(�.KL,LclI'� New Residential 81dgs.&Pools� EACH NO. FEE
� Certified copy is hereby turnished. i&2•Family,5q.Ft. 5 — S LOCALITY
MUlti•family Sq.Ft. NEAREST
ertlfied copy is filed with the county 6uilding inspection CROSS ST
�department. Residential Swimming Pools OWNER Ofi
//�� FIRM NAME �•'
Date/�;� / Applicant Outlets:Rec.�Li9ht�Sw. � � ^ MAIL
' •First 2� ADDRESS I ' "�'�
, CERTIF[CATE OF EXEb1PT10N FROhf WORK�RS' Total No.�� Additi0nal " CITY �. Tel No.�� � �
COM1IPENSATION INSURANCE ,. PLAN CHECK q
� APPLICANT O
(This section nced nnt be completed if t]�e work involved � Lighting Fixtures First 20 �, ADDRE55 � V
by the permit is for one hundred dotlars (3100)or less.) Addicional � �
� - Total No..��--� ' CITv Tel No. . - O
I certify that in the perfnrmance of the work tor which this Fixed Appliances Not Over 1 HP h
permit is issued,I shall not employ any ptrson in uny manner. PEAMIT / �
so as to become subject to the 1Vorkers'Compensatinn Ln�vs. Range_Hearer D.W._ APPUCANT W
�
� � � Oven _Dryer_W.M._ AODRESS� i/. � . y
Date A licant L
Pr • Top _FAU W.H.� CITV Tel No.
Hood_Fan �Other_ �
NOTICF TO APPLICANT=lt,atter making this Certificate ot Disp. _Room Air Cond` �.G l-ICE S O
Exemptian, you should�hernme suhject to the Workers' � - HEG.NUM9ER Clase —
Compenxatinn proeisions of the Labor Code,you must torth- Power Apparatus&Large Appliances DISTRICT NO. PROCESSED BY
avith camply with such provisions or this permit shal� be Size&Type HP,KW,KVA,or KVAR �
Jeemed revoked. � �� ����
� , Up To 1 Incl, FINAL
LICC•NSED COVTRACTORS DECLARATION � � Over 1 to 101nc1.n(�� DATE ?! p�/ VALIDATION
. Over 10 to 50 Incl. � �
I hereby affirm that 1 am licensed under provisions ot Chaprer Over 50 tD 700 InC. eV A� �
9(commencing wi[h Section 7D00)oP Divisinn 3 ot the Busi•. Over 100 � �
ness and Protessions,Code,and my Iicense is in full force and '�
eifect. Services � -
� License Number-3v��`� Lic Ciass �� 0�200 Amp.Under 600 V� �� � � .
. 207-1000 Amp.Under 600 V _
Contractor Date Over 1000 Amp.or Over 600 V
. �7020A
HOM1iE 01VNER•HUILDL•R DECLARATION Temp.Power Pole&Appurtenances � �
� Sign with One Branch Circuit #',��� ��� �2
I hereby affirm that I am exempt from the Contractor's qdditionai Sign Branch Circuits � �
License Law for the foliowing rrason(Section 7031.5,8usi- ���� •5 2 3 0 -
ness and Professions Code): .
Misc.Conduits&Conductors '!.• •5 2 J��
� ], as owmer of the property.will do the u�ork and the Othe (Se Camplete Fee Schedulel— '
sirvcture is not iMended or offered for sale (section � � �O 4 P O�8� � � �
7044,Rusiness and Professions Code). ,
CONSTRUCTION LENDINC ACFNCY . �
1 hereby affirm that there is a construction lending agency . � �
fnr the performance of the work for�vhich ihis permit is pERMIT FEE � ISub-Total)
issued(Sce.3097,Civ.C.). � � �
Lender's Name PLAN CHECKING FEE (One•Fourth Permit Fee) �
Lender•s Address pERMIT ISSUING FEE 7G
I certity that I have read this application and state that the TOTAL FEE - ' �� . � �
ebove information is correct.I agree to comply with all County ,l l �
ordinances and State laws reguiating Eleetrical wiring, and ' .71Z•/L�
hereby authorir.e representatives of this County to enler upon �
'the v�mentioned property for inspection purposes. SEE'REVERSE FOR EXPLANATORY LANGUAGE
Signature of ermrttee� -�j��1�yg � . .. . . .
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