HomeMy WebLinkAbout1188 DIAMOND BAR BLVD (7) 1VORKBRS'COAIPENSATIONDECLARATION 176A663 APPLICATION FOR ELECTRICAL PERMIT ///777 �
_ CE�8D6G(2-801 � �
[ here6y atfirm that I have a certifcate of mnsent ro self COUNTV OF LOS ANGELES � BUILDING AND AFETY
insure,or a certificate ot Workers'Compensation Insurance,or � ��
a ceriified copy thereof(Sec.3800,l.ab.C.) " �
���� FOR APPLICANT TO FILL IN JO �,p� �,�A
� A�ORESS ��lYv D/�r�LU/Up 8�'
� Policy NK,!_L�Cnmpany��lj/�'��� � New Residential Bldgs.&Pools EACH NO. FEE �c �
� Certitied copy is hereby fumished. . � 1&2-Family,Sq.Ft. S — 5 LOCAIITV D/��(�/�/� 8���
� � Multi•family Sq.Ft. — NEAREST �
� Certified copy is filed with the county building Inspection ' Residential Swimming Pools . � CROSS ST �.���L�
department. OWNER OR �M 1,��
G/ �,��� �w .,..f��n�� /�� U FIRM NAME M
Date�Applicant�-�(�����"1 c�-'/c'���LGL� OuNets:Rec!��Li9ht_Sw.� / 7�
First20 � AODRESS �t7oO Y (I�
� CI:RTIFfCATG OP EXETIPTION PR0�7�VORKLRS' Total No.� Additional � CITV Nf{J�, B�H. Tel No.7 5��g�I� '
� . .CO�IPENSATION INSURANCE . }
. PLANCHECK � s��I � Q
� APPLICANT LF .
(This section need not be completed it�lie work involved Lighting Fixtures � First 20 � aooReSs
6y the permit is for one hundred dollazs(5100)orless.) � - 7 S• N� �
Additional /
I ttrtity that in the performance ot the work for whlch this F zed Appliances Not Over 1 HP CITY��1jf� A � Tel No.6s�^�,��� V
permit is issued,I shall not employ any person in any manner pERMIT �y
so as to become subject to the 1Vorkers'Compensstion Laws. Range_Heater_D.W. � APPLICANT � ' p.
� � . � Oven _Dryer_W.M._ AO�RESS �r 7�
Date Applicant ToP —FAU _W.H,_
Hood_Fan _Other_ CITv /( , Tei No. C/
NOT7CG TO AI'PLICANT:If,after making ihis Certificate of Disp. _Roam Air Cond._ LICENSE OR ��JA���ass C--�"�Q '
Esemption, yov should become subject to the Workers' REG.NUMBER .J�tV :
Compensation prorisions of the Lobor Code,ynu must forth• Power Apparatus&Large Appliances DISTRICT NO. PROCES D 9Y
with comply �vith such provisions or this permit shali be. Size&Type HP,KW,KVA,or KVAR �
deemed revoked. . Up to 1 Incl. _ !O
� Over 1 to 10 Incl. DIATEL ^ �
LICENSED CONTRACTORS DLCLARATION —� Over 70 to 50 Incl. " I oC I� �/ VAL ATION �
I hereby af(irm that I am licensed under provisions of Chapter Over 50 to 100 Ina FINAL � � �
BY
9 (cnmmencing�vith Sectinn 7000)of nivision 3 of the Ausi• Over 100 •
ness and Rofessions Code,and my license is in full force anJ �
effect. � - Services � /� �
Licenze Numbe6�u-.e�--v�c. Lia Class��ID. 0-200 Amp.Under 600 V � . . •
�)��.r7 ,/ 207-1000 Amp.Under 600 V
Contractor�7Uv!�'�C���Date��`Y'� Over 1000 Amp.or Over 600 V . . �.
, 1tOJ1E 0�5NER-BUILDER D[CLARATION � Temp.Power Pole&Appurtenances � -
I hereby aftirm that I am ezempt from the Contractor's Sign with One 8ranch Circuit " L S'$(��j a
License Law for Il�e following reason(Stctian 7031.5,Busi- Additional Siqn Branch Circuits .
nessand ProfessionsCode): #ei ,•.�2
Misc.Conduits&Cnnducton �
� I,as nwner nf the property,�vill do the work and the p�her ISee Complete Fee Schedulel— . � • •3�'`��
structure is not intenJed or a(fered for sale (Sedion ' � �
7044,Business and Nrofessions Code). . . •'���3 7.3 0�
CONSTRUCTION LEN�ING AOENCY ' �
I hereby,affirm that there is a construction�ending aFency � . �O 9.C U—S�
for the performance of ihe�vork fo* whkh this permit is pERMIT FEE ISub-Totaq � . ' '
issued(Sec.7097,Civ.CJ. . � � �
Lender's Name PIAN CHECKING FEE IOne•Fourth Permit Fee) - �
Lender's Address PERMIT ISSUING FEE O
1 certity thst t have resd this applicatlon and state that the TOTAL FE� � � (�
above information is correct.I agree to comply with all County . '
nrdinances and State la��s reguiating I7ectrical�viring, and � .
hereby aulhorize representatives of this Cnunty to enter upon � - � ' -
the a ove-menNnnF3� rope ty Pnr . ec' n purposes. . . -
�� SEE'REVERSE FOR EXPLANATORY LANGUACE �
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