HomeMy WebLinkAbout0080A VJO4KER5'COMPENSATION DECLARAT�ON 76A667 10�81 '
I hereby o(firm ih�l I have n cerlilitote o�CO�SP.�i 10 SPI( �E-� APPLICATION FOR ELECTRICAL PERMIT 3 �
ins�re,or a cerrlficate.of Workers'Compensat�on Insuroncc, COUNTY OF 1p5 ANGELES BUILDING AND SAFETY
o�a ce�i�Red copy thereof(Sec.3H00,Lob.C.)
a�YN7F)�.JBZOIOomponI� INS BROKERS FORAPPLIUMTOFlLLIH !OB
CertiFied capy i5 hCre�y f�rnishnt�. EACH NO. FEE �'D�4E5
New Res�dentiol Bldgs.8 P��is
� CerliFied copy is filed wi�h Ihe coumy bu�ld�ng inspec- I 8�-Fomily,Sq.F�. f — E � IOCALITY DIAMOND BAR
IiOn[leparlmenl. Multi-fomily Sq.FI.� — NEARESf DIAMOND BAR & GRAND AVE
CRO55 ST.
11-16-83 f1TATMAN ELECTRIC Residentiol5wimming Pools
Dote Applimn OWNFR OR
Fi�M N,v,uEPRESLEY OF SO CALIFORNI
CERTIFICATE OF E%EMPTION FROM WORKERS' pu�e�s:Rec�light�Sw./ M''�'� CAMPUS DRIVE
COMPENSATION INSURANCE �CDRF55
(This��ttien n��d nef b�templ�fad if Ihe wark Inrolv�d by First 70
Iha parmlt Is For one hundred dollars(5100)er loss.) To!al No._� Add�nonal arvNEWPORT BEACH iel.Nd 4O—O$OO
rinry cr�cK
I cerii(y fhoi in the perlormnnce of the wnrk(cr which�his AFPLICANT
pPrmi�is issuad,I Sholl rc�emplcy any person in any monner
so ns lo bacome subjet��o the Workers'Cnmpensation Laws. Li9hfing Fi�Nres First 20 ADDRE55
To�al No.� Additional
Dote Appl�cani CITY Tel.No.
NOTICE TO APPIICANT: If, of!er moking fhis Certificaie o! Fi�ed Applinnces Nol Over 1 HP �4MiT WATMAN ELECTRIC INC
Exemp��on, yau should become subject io �he Wo�ke�s' Ronge_Hea�er_D.W.— �����ANT
Compensniion provisions of Ihe Lobor Code.vou must(orrh- Oven _Dryer _W.M.— ADDRESS .
wi�h comply with such provisions or this permil sholl ba Top _FAU —W.H.—
deamedrevoke.d. CITY EL TORO 92630rei.Na.8598108
LICENSED CONTRACTORS DECLARATION Hood _Fan _Oiher_
D�s —Room Air Cond. _ t':fNSE OR
Il�erebyo4firm!hetlamlicensedunderprovisionsoiChap�er9 P' �EG.NUMAfR 433174 Closs.C—]_Q
(cor*�me�rin�with Sectir.n 7000)ei Divisien 3 oF ihe Busfr.ess power Appnrnius 8 Large Applionces DISTRICT NO. PROCES BY }
and?�o(ess�ons Cocfe,nnd my lice.nse is in full force and effecl. d
433174 (,'-7_0 Sirr.8 Type HP,KW,KVA,or KVAR �
licensc Numbcr lit.Closs Up fo I Incl. / V
fINAL
O�nr 1�0 10 Incl. DATE ��l��,G�t� YAIIDATION �
Con�racro�r�`i'�N F.T.F.C`TSD�k,' 11-1(�—�'� Over IO lo SO lnd. � � �
❑ I om eRempt�ndr.�Sec. Over 50 l0 100 Inc. BY AL �) � W
� 8.8P.C.ior ihis reoson Over 100 �.���'- �•�'"t— N
Dare: Services,Swbd.,MCC R Panelboa�ds � � Z
D-ZN Amp.Under 60D V
S�gnature 401-1000 Amp.Under 600 V
OOvqr 1000 Amp.or Over 600 V ;��.�l G li i�l
E.emp�ion for Rrg.fAainL EleU.
i; . ee . .,.
S!":GLE F,",�ti',1LY Temp.Power Po�r.8 Appurtenc�ces
HO"J�E OWNFR�HUIIDER DECLARATION Sign with One 8ranch Circui� � e e j��O
I hereyy c(firm thoi I om errmrt Irom�ti�Con�roclei s Lic=nse Adaii�en^I Sign arench[ir;ui!s �
Law for Ih�I�Ilowing reoson(Section 7031.5, Business and ��� �? _
Prolrssions Code): . `"— '-
� Misc.Conduits 8 Conducrors � � � �_Fj�
I,os owner of ehe pro�erty,will do�hc work ond 1he
strucWre is not inrended cr offcred fcr sale (Section OIFIPI�SCP.COI'IrIPtP FPP SChPdUIQ�_ ,
704a,Bus�ness and Professions Codr). �
CONSTRUCTION IENDING AGENCY
I hereby oflirm iha�ihern�s a cons'�uction lending oqency 1or
Ihe p=rformonce of the work(or which ihis pe�m�t is issued pERM1T FEE (Sub-To�al)
(Sec.3097,Civ.C.).
PIAN CHECKING FEE
Lander's Nome
PERMIT ISSUING FEE (�' Q
Lender i Address
I cerYly thot I Fove rnnd rhis app!�ca�ion and s��te thai thc TOTAL FEE �.1,�
obove informarlon Is co�rect.I a��e.e�o comply wiih all County
ord�nences d Sta!�laws requlating EleUrical wiring,and
hereb ori�c represenratives of this Counly io en�er upon
�he o e-memioned propert lar��specron�u�Peses. SEE REVERSE FOR EXPLANATORY LANGUAGE
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