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1180 DIAMOND BAR BLVD (16)
�- � WORK�RS tDI�iPLNSATIONDECT.AIZATION �_�� � 76A663' �. APPLiC�ATIO.IV�� �FC�R� ELECTRICAL��PERMIT�� `� � �� , CE�IIO6G(280) .. . �� . , � ,t herehy af.fi m ihat 1 h�ve a certifmate of consent tn.celt' - ' COUNTY OF LOS.ANGELES � BUILDING AND SAFETY � � insure,or�certificnte o4 Workers'Compensation InsurunCe,or � � �. � . . � , _ _ � a cer[ified"�copY�tnhereo/f�(S'ec.,.���B00,I.a1 ..) , . . � 1'nlicy Ldu,� c��`"('�mp ny �����/� _ FOR APPLICANT TO EACH N NO. FEE AD�RESS I� � / ��<-"' '��✓ . - New Residential Bldgs.&Pools � ���"�J� $ — $ LOCALITY , p. 7 ff1�'� ;.� Certii'icd copy is hereby furnished. 7&2-Family,Sq.Ft. � ���� � '❑ Multi-fdmily Sq.Ft. — � NEARES7 !f . — . Certified copy is file�with th county building inspection CROSS ST ,�.✓',�>9�✓-� dxpar(ment. . �� ResidenYiaf Swimmin9 Pools OWNER OR-/ � .. � ���,//,/`/-- FIRM NAMrL� a.�i9�?JlJ/S �� °'✓` : llata��Applicant �2 `"'"'�(" '�" � ; Outfets�,Rec.._LVght._Sw._ MAII � � �/ s�(Jljb� �� . '. � . . First 2O ADDRESS �.�_CI_TG�T/ _ � � ��' �� CERTiFI(IATr OP P:XF'69PTION FROM WONKERS' ToWI N�.._._ Acidit+vnal CISV ���/� Tei No�� ��/j�/ �l - COYIPHNSA'TION INSURANCF. � � _��... ., ' � � . PLA CHECK �a �� � APPLiCRNT ;;� , (This sectiun need not be completed if the wurk invoived ��Lighting Fixtures . First 20 AooRess � �V � ,.�� by the pe:mit i,s t'or one hundred dollars (8100)ox less) qdditional __... : � � Total No. -"� � � � �1 cert�fy�that in tfie perf'ormance uf the wo�ic foi which[his �."Fixed Appliances NOt Over 1 HP CITV - Tel No. r�-�� .�:perroil is i3eued;1 shall nut employ any porson�n any manner �. PERMIT ���yl � ,�y7 ,,U �. su ac to become subject to the Work.erc'C�mpens,itiun Laws `� Range_Heater D.W._ APPI.ICANTY�<Q �� ,{p�� '.di! � � : . ��. Oven ��ryPr_W.M._ ADDRE55� �j.��: �,�"��/r°�y`L_.� �;.�. �� Unte Applic�ni � '� Top _FAU _W.H..� '—�-��-- ,4 . I, � -- , Hood_Fan _Other_._ � CiTY�,��r����„- .Tel No�13 r�"7�' � �NOTICE TO AI'YLICAN'f.If,af[er n�akmg thi�C�rtificatc.^,: : pisU. —Room Air Cond._ II LICENSE OR - -�� ��� �a (x���Exemption, you shuuld becnme suhject to the Workers' 1-- , REG.NUMeER�"�J�� .7 Class C;"✓� � �Comp�nsatior,provisions ot the Labor Code,ynu must forth �� �power Apparatus&Large Appliances 1 DISTRICT NO. PROCESSED BY . ,�,with comply with such�provisions or this permit shall be ' Size&Ty}�eHP,KW,KVA,orKVAR - .�deem�d revohed. � - ' �Q ��� . .. Up to 1 Incl. - FINAL � � �e Over t to 10!ncl. oaTE �/ � �', VALI�ATION i, .. LIC}.NSl�:D CONTItACTORS DECLARAI'ION . ' pver 10 to 50 Incl. #t .�1 heroby aff'irm that I am licensed under provivinns of'Chnpter — Over 50 to 100 Ina FINAL � � !i 9 (cnmmencing with Section 700o)�nT Urv�sion 3 oT the Busi � Over 100 � BY � { ness;.nd Professions.Code,,onQ my licence is in tull force.ind - � � 7� effect. �� ServiCes �- , �C''� }���"� ('7.-�(� 0-2D0 Amp.Under600 V ��. . . , T icense Numbed� Lic.Claae - - � . ��+�, ( C1 ��/ 1� 201-1000 Amp.Under 600 V� __. :-('ontructtir/�LG'�if��,lj ����%__.1/''�/��/� Over7000Amp.orOver600�V . , � � � f-. � fiOME O�4N t+R BUll.n1;I2 DFC�.a!LP,TIOD? �yTemp.Power Pole�Appurtenances - � � �!L heceby affirm tVtat I ;�m exempt from tfie Cnntxaetot'S 9Sign wiYh One Braoch Circuit � � I,icense L.�w fbr the fulimon,p. o (c.,_y.,� a � �.e. �tAdditional Sian R _h C�.c_._ . . . 'ne.es and Professions Code): � ". ,V .. ., � ' � .�', , �Misc.Conduits&Conductors I, xs pwner of��the progerty,will do the�werk end :h� � � .� 0 �Other(See Comptete Fee Schedule)-- . . `- structure is no[ intended iir offered for sa'.e (S:pctiUn +:, �� .;�, .-. _..- -.—._ ,.. 7044,Bus�ness and Profcssions Code). . CONSTRUCTfUN I..LNDING AUL:NCY �—..----- "—� . . . ��7 hereby affirm that thcre is ii construction lending agr.ncy �. �',for the�perfocmance uf thu �vork for which tl�is parmit is pERMIT FEE (Sub-Totall �� -:'issued(Sec.3097,�Civ.C.). ' .J Lendur's Name p�.pp.�CHECKff�G FEE (One-�ourth Permlt Fee) ���������� � � ��i Lcnder's AJdress _ � �� , . .'f�o e m u a 2 - — PERMtT ISSUING FEE �Qa�. - �. _ ;1 tcr[ify that i have read this applica?ioit and state tliut khe TOTAL FEE '�¢� . �� � g�' 7'L�� �� �;above informatio�i is correct.I agree to coinply�vith all Cuimty � - �O � � � �O�`, ':lordinanCcs an "State laws regulating Electricul wfring, and . . � __ ;heseBy autho ie representutiv s of this County tu en[er.upon - ' � .the abnv�- ntioned proF� . for ins ectiun purposes. r '' I,��'Pi n ' ,� �J SEE�ItI•;VG2SE PpR EXPI,ANqTORY LANG[IACE: . � , �-�`��� . 5 Sigm tuxe aS Permittee Datc • . . � � � . ; � � ', ' , � � : � f, � � � � �, � � , � �� � . � , � , � , � , , � , � , � �. � � , � ..�.Y. ,, � � � � � . � 0 1 �� , 1 .` . l �. 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