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HomeMy WebLinkAbout1184 DIAMOND BAR (10) WORKHRS'COMPENSATION OECLARATION � � 76A663 APPLICATION FOR �ELECTRICAL PERMIT � {� � . CE�BO6G(2�601 1 hereby affirrn.that I ha�•e a certificate ot consent to xlt � COUNTY OF LOS ANGELES BUILDING AND SAFETY �J insure,or a certificate ot Workers'CompensaUon Insurance,or.I � - a certified copy thereof(Sec.3800,Lab.CJ �����2��7 FOR APPL�CANTTO FILL IN . JOB � Policy N�RYSc_�"_"'C�mpany � � New R¢Sid2ntial 81dg8.&P0o15 EACH NO. FEE ADDRESS � � Certified copy is hereby turnished. � - 1&2-Family,5q.Ft. $ — $ � LOCALITY ((3mVN n , � Multi-family Sq.Ft. — � OCertified rnpy Is filed with the county building inspection � � CROSS ST 4(=� department. Residential Swimming Pools OWNER OR rt�e�� �7 FIRM NAME Date�.c�Appiica �Y���� Outlets:Rea_Li9ht_Sw._ - MAIL —� �'7 . -� � � First 20 ADDHESS �ZZ'�jptitLl�VCA kW CLRTIFICATE OF EXF.MPTION FROM WORKERS' Totat No. AAditional CITv � (' Tei No. _ 2 } - .CONPENSATION INSURANCE � P�qN CtiECK �- (Th13 Sec[i00 �e2d �Ot b¢C011lpl¢tEd iP th¢wOtk I/lvolved ' APPLICANT V by the.permit is for one hundred dollars (5100)or►ess.) Lighting Fixtures First 20 ADDRESS � . Additional � � � � � Total No. ' � CITY Tel No. 1 certify that in�he pertormance of Ihe work for which this - Fixed Appliances Not Over 7 HP � ~ permit is Issued,I shall not employ any peroon in any manner PERMIT V' so as to become subject to the Workers'ComPensation Laws.� Ranqe_Heater_O.W._ APPLICANT ^ � N . . .. . , �.. � . Ovnn _Oryar_W.M._- ADDRE55 � C7Th P , . Date AODlicent - Top _FAU _W.H._ , CITV — TsINo.�I'�. — Hood_Fa� _Other_ 2— � NOTICE TO APPLICANT:if,afier making this Certificate of pigp, _Room Air Cond._�. LICENSE O I:xemptton, you should become subject to ihe Workers' . REG.NVMBER Clns �%' Compensation provisions ot the Labor Code,you must forth- power Apparatus&Large Appliances DISTHICT NO. PROCESSED BV �vith comply with such provisions or this�permit shail be Size&Type HP,KW,KVA,or KVAR � deemed revoked. � • � �— �� �\ . Up to 7 I nel. ,� d FINAL �_ Overltot0lnc�. �oaTe � �/, �� VALI�ATION LICENSED CONTRACTORS DECLARATION Over 10 to 50 Incl, I hereby affirm ihat I am licensed under provisions of Chapter Over 50 to 1D0 Ine. By'°'L . 9 (commencing with Section 7000)of Division 3 of the Rusi- Over 100 • ness and Protessions Code,and my license is in full force and � . . . - effect. � . . Services � � . License Numher� '5��� Lic.Class� �`�� 0•200 Amp.Under 600 V - � . � ' �+ 201-1000 Amp.Under 600 V CoMract �_Date 7�ZZ—J � Over 1000 Amp,or Over 600 V- . � HOME OWNER•BUILDER DECLARATION Temp.Power Pote&Appurtenances . 1 hereby affirm that I am exem t from ihe Contractor's Sign with One Branch Circuit - License Law tor the.following rea on(Section 7031.5,Busi- Additional Sign Branch Circuits . �°v�i Q u�i ness and Profasions Code): - � � ' ' � MisaConduits&Conductors #.�'��• • •2 � i � I,as owner of ihe property,wiV do the work and the - Other(See Complete Fee Seheduie)— � � strucfure is not intended or otfered for sale (Section � 'I����ll..'],rJ� � � 7044,Business and Professions Code). � - � � CONSTRUCTION LF.ND[NG A(3ENCY • • •4 Z 5 0 c=.� I hereby affirm�that�there is a tonstrucNon lending agency � � � � � ' . for the performance af the �vork for which this prrmit is pERMIT FEE - (Suh-Total� . �Z 2 2"$.� issued(Sec.3097,Civ.C.). � � . ' Lender's Name PLAN CHECKING FEE • (One•Fourth Permit Feel . � Lender's Address � pERMIT ISSUING FEE . i certify that I have read this appiication and state ihat�he TOTAL FEE � � . above informetion Is torrect.I agree�to comply with a�l County . . � � , .ordinances and State laws regulating Tlectdcal wiring, and hereby authorize representatives of Ihis County to enter upan � � � - � ihe above- ention property tor inspection purposes. SEE'RCVERSB FOR BRPLANATORY LANGUAGE - / � / � A �7f.�'r.1�4� —Z Signa�ure of Ytrmiltee De� - . , � ' � �- , .. .. . , .,,_.. ,.. I _ ..i. ._ i .. /i _. ' � • - . ' I.. i. .~-' 1 ' - -� � C a . . ' . ' i.. ' . -• • . . , . . , ! . . • ... c- _ , ... ,. ' . . , .. � . U�` . � � . . . . . � i i . . � - i ,_ . � _ � ' . � ' � � � � --� --- - . � � _ - ' ,. '- . ' �. .. � ! . � ` �- • ' f � " � 4� ' z „ 'c �o ,T � 9 c -+�- - . 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