HomeMy WebLinkAbout1180 S DIAMOND BAR BLVD (9) WORKERS'COMPENSATION DECLARATION '���3 �o,e� qpp��CATION FOR ELECTRICAL PERMIT �
I hereby offirm thot I have a cer�i{itate of consenl to self �E-�
insvre,o�o tertificatn of Workers'Compensotion Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a cer�iiied copy thereaf(Sec.380D,La6.C.� � �
P❑olicy No. Company fOR A►►LICAM TO Fllt IN ADDRFSS I I '� H ,
Cerlified copy is hereby iurnished. New Residen�ial Bldgs.8 Pools EACH NO. FEE
� Cerlified topy is filed with 1he tounty building inspec- 1 8 2•Family,Sq.Ft. s = E ��A�ITY- � � �,
�ion department.� � � Molli-family Sq.Ft. taEnReSi G R�a w c� i
� Residenfial Swimming PODIS OWNER OR �y
Date AppliCaM � � FIRMNAME S �W A Y �uJ�' '
CERTIFICATE OF EXEMPTION FROM WORKERS' � 1 �i� �
� COMPENSATION INSURANCE- Outlets:Rec_Light_Sw._ n pDDRESS SA �v �
First 20 �
- (This��ction n�ad not hs completsd if ths work Inrolved by Tofol No. Addilional CITY � . Tel.No.
th�permit fs!or ona hund�ad dollnrs(5100)or less.) pinN CNEIX
I certiFy that in the performance of the�work�f which�his qppliCaM � ��
permit is issued,I sholl not employ any perso a y mannar
so az to becAme s�bject to ihe Workers'Co ens tion lawe. Lighting Fi.tures � First 20 ADDRESS
� /�L JL, � � � � Addilional
� � To�al No. CITY Ta!!No.
Do�e �� epplicant Fiaed Applionces Not Over 1 HP PERMIT � p
NOTICE TO APPLICANT: If, afrer mokin rhis Certifit �e of AaPUCAM '4 tL E ►J LZ, �JJ('/
Exemp�ion, you should become subjact to �he Workers' Range_Heater_D.W._
Campensarion provisions of the lobor Code,you must forth- Oven _Dryer —W.M.— � ADDRE55�37 E M�$S 1�N f�V
with comply wiih s�ch provisions or�Ihis permit shall be Top _FAU —W.H.— 7i �
deemed revoked. � � - CITY O�tq p n/a �( Tel.No. 2 _73 r�
Hood _Fan _Other_
UCENSED CONTRACTORS DECLARATION uCENSE OR
I hereby affirm that I am licensed under provisions of Chopter 9 �isp. _Room Aif Cond. — RFG.NUMBER 3 4�Y�'7 . c�a�s.�-�e1
(commencing with Section 700D)of�ivision 3 of�he Buslness . DISTRICT NO. PROCESSEO 8Y -
ond Professions Code,ond my license is in full force and eHect. I Power Apporatus 8 Large Appliances /v . �
iu .7 . Size 8 Type HP,KW,KVA,or KVAR� � v
license Num6er 3 g'� �& Lic.Closs C- �� Up l0 1 IncL FINAL r
�NC r Over 1 ro 10 Incl. DATE ��,� 5 YALIDATION �
Contractor��.'���E�A NDCL Da�e 2/lj/r� Over 10 to 50 Incl. FINAL � V �
❑ I am e*empt onder Sec. Over 50 to 100 Inc. BY w �
� Over 100 . Z .
8.8P.C.for ihis reason -
Da e: � � Services,Swbd.,MCC 8 Panelboords ' �� - � � � ' �
0-200 Amp.Under 600 V
5';o�e e � �/( �/' 401-1000 Amp.Under 600 V � . . .
Over 1000 Amp.or Over 600 V �
� Exemption for Reg.Main1.Eled. . - � � .-�.^_•$3�(�a � i
SINGLE FAMILY . iemp.Power Pole 8 Appurtenances � .
HOME OWNER-BUILDER DECLARATION � - � � ��.•��• • • •Z
Sign with One Bronch Cirtuif ,I • •�',1.�5
1 hereby affirm tha�I am exempt from Ihe Confroctoi 5 Litense . Additionol Sign Bronch Circ�ifi� �� �
Law fcr Ihe follcwing reoson(Secticn 7031.5,Busir.ess end �
Professions Code): - • • • ���.2 J�c=i '
❑ I,as owner of the properfy,will do ihe work and�he M:sc.Condui�s 8 Conductors �- 0�
strudure is not in�ended or offered for sale(Section Other(See Comple�e Fee Schedule)_ ► 2 2 2`8 5 ,
7044,Business and Proiessions Code). .
CONSTRUCTION LEND�NG AGENCY . . � � � -- -
I hereby alfirm that there is o constroction lending agency for ��
the performonce of the work for which Ihis permit is issued � � PERMIT FEE- � � (Sub-Total) �" - � ��� -
(Sec.3097,Civ.C.).
� � � PIAN CHECKING FEE� � � . . . . ,
lender's Name - - . �
PERMIT ISSLIING FEE , . �d y _
lender's Address � - �
I certify tha�I hove read ihis applicotion and s�ote that�he iOTAL FEE �� ,z!j , � _ _
obove informa�ion is correU.I agree to comply wiih all Coonty . ,
o�dinonces ond Sto�e laws regulating Electrical wiring,and _ . � •
hereby authorize�e se ta�ives of this Covnty�o enter upon . � .
the m io d pr perty for in5pettion pu oses. � ' �
���/p,✓ SEE REVERSE FOR EXPLANATORY IANGUAGE
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ignarore o erminee Dare -
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