HomeMy WebLinkAbout1180 DIAMOND BAR BLVD (3) �w_ ' _cF:-
���WORKERS'COMPENSATION DECIARATION 76A66� 10/el �
`"~' hereby aifirm�h�ti.l hove a tertificate of�o�,e�,,o self �E-� APPLICATION FOR ELECTRICAL PERMIT
�{sure,oIa cenificate of Wo�kers'Compensarion Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
o/$''S�'rfrfied cop the2reoi Sec.3800,tab.C.) .� .
O( NS�"��✓�mP4YFR�MON7'.J�1/D.EM�1I, FORAPPIICANTi0i1lLIN � � JOB � � .
� O �i r, Rt✓D
Certified copy is he�eby furnished, , New Residenfiol Bldgs.8 Pools EACH NO. FEE ADDRE55
a Certi(ied topy is filed with Ihe county building Inspet- 1 8 2-Fomily,Sq.Ft, 5 — 3 IOCALITY � �
tion deparlment. - . Muhi-tomily Sq.Ff. ' NEAREST
` CROSS ST.
Residentiol Swimmin Pools �
Dale Applicant - . 9 �_. :_� �.,, OWNEROR .�I
�{� '�y`� tIRM NAME A
CERTIFICATE OF EXEMPTION FROM WORKER$' Qutlets:Ree%�� Lighl r2z$w,�� y V ��L
COMPENSATION INSURANCE • � �7/J-`, �' yd'�s AD�RESS l.iJ /�, �� A �� '
(This aMlon ns�d not b�eomplH�d ii th�work invelvad by Firs�2Q� .
fhs p�rmlt 1�for one hundrod dollon(5100)or lefs.) To�al No,�_ Addilional� ..� 7 , ��TM tU Tet.No.C� �,�.
I certify fhol in fhe performance of the work for which this PIaNCHECK �
permil is issued,I sholl not employ ony person in any manner APPLICANT J
so as to become su6ject�o the Workers'Compensotion Lows. Lighting Fiatures Firsl 20 ADDRE55 - -
Tofal No. 1•�-Z. Additional .
CITY � � Tel.No.
Dale- Applimnl Fixed Applionces Noi Over 1 HP ��� � 5�
NOTICE TO APPLICANT:_If, afler making this Certifica�e oi PERMiT '`��
Exemption,� yoo should betome subiec� to Ihe Workers' Ro�9e�Heoler_D.W._ APPIIfANT �j- /1�. �(tK.TK�G /Kl G /,
Compensotion provisicrs cf!��Leb^r C^�+e;yeo m�sl for�h- Oven _Dryer _W.M._ - -ADDRESS�cl$-y 7 LL FF N IVE�, �'� '
wilh comply with s�ch provisions ar �his permit shall be Top _FAU —W.H..._
deemed revoked. - Hoad _Pon _Other_ --"� CITY �_ _���. � Tel.No.2 3 .
LICENSED CONTRACTORS DECLARATION uCENSe OR �
I hereby affirm ihal I am licensed under provisions of Chopler 9 �'sp. �Room Air Cond. _ REG.NUMBER 3 5 3 5 Class �C[' �
(commancing wiih Section 7000)of Oivision 3 of�fie Business � power Apparolus 8 Large Appliances DISTRICT NO. PROCESS 0 BY �
and Professions Code,and my license is in full force ond e{fect. `� . � �
�3 SS,3� �' ��� Size 8 Type HP,KW.KVA,or KVAR - ' O
license Number Lic Closs Up l0 1 Ind.. ` FINAL 7� V �
CoMroclorG�K�G/rc7 /li4pale /�—�"Z7� .. � Over 1 10 IOlnd. �. DATE / i/ VAUDATION 0
❑ Over 10 l0 50 Incl. �
FINQI
�am e.empt under Sec. Over 50 to 100 Inc. BY �W
B.BP.C.tor this reoson Over 100 � N 1
y n Services,Sw6d.,MCC&Panelboards � , Z -�
/°re•T7� 0-200 Amp.Under 600 V -
Sinnnr��rP a 1��_ 201-1000 Amp.Under 600 V - � :%J��,`]�
OOver 1000 Amp.or Ovcr 600 V. . •
Exemp�ion for Reg.Main�.El=ct, ` ft e • • •2
SINGLE PAMILY - Temp.Powcr Pole 8 Appurienonces. � • � �(�5�
HOME OWNER-BUIIDER DECLARATION Sign wilh One 8rancR Circuit �
I hereby af(irm thal I am exempt from the Controttor's license A�,���;��,��Sign 5rnnch Circuirs ° ° � (:�l,J��
Law tor the following reason(Section 7031.5, Business and � - ----- -�-.--_. ___.__
Professions Code�: I �.0 6—f5%
❑ I,as owner oi Ihe properfy,will do the work ond Ihe Misa�Conduits 8 Conductors � -�- - � _ . .
structure is not iMended or offered for sole(Section Other(See Complete Fee Schedule)_ ,
7044,Business and Professions Code). � � - � � � � ��� -- - � � �
CONSTRUCTION LENDING AGENCY - �
I hereby afiirm�hat there is a consrrudion lending ogency for �
the performonce of the work for which this permit is issoed PERMIT FEE - - (Sub-Total) �7�. � �
(Sec 3097.Civ.C.�. � - . .
- PLAN CHECKING.FEE �
lender's Name ' �o, � � � �� � � '
PERMIT ISSl11NG FEE �
Lender's Address � . � �
I certify ihot 1 hove reod Ihis applitafion and stoie thot the TOTAL FEE /8 .� �
above informaiion iz mrred.I agree io comply with oli Coumy � � ��
ordinances and State laws reg�lating Elettritol wiring,and
hereby au� rize reprezen� �ives of this County ro emer upon � �� � . ..
Ihe ob e liane p rly for inspettion purpose5.
- SEE REVERSE FOR E%PLANATORY LANGUAGE
//-���
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