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HomeMy WebLinkAbout1180 S DIAMOND BAR BLVD (11) I " WORKERS'COMPENSATIONDECLARATION � 76A663 ,o�e, APP��CATION FOR ELECTRICAL PERMIT � � � � I h?reby affirm that I havc a certificate of consent to self insure, Ce•8o6G or a certi�ics!e ot Workers'Compensation Insurance,or a certified COUNTY F LOS ANGELES BUILDING AND SAFETY �co thereof(Sec.3800.Lab.C.) wG+f�jSStI�j3 ��{y�yycri FOR AVP ICANT TO Flll IN JOB �a� ��� olicy o. � Compary 7. �- ❑ .Certified copy is hereby furnishe�i'�.�� �' � EACN N0. FEE. . �or+E55 ' � . New Residential Bldgs.&Pools . 5,t._, � g — g IOCALITY YV� ll ��� Certiliod copy is filed�wilh the couny buildirg inspectian ��2•Famiiy,Sq.F4' /�1 � � , , � — NEAREST r� ^� I - 1 p^ar m t . , . Multi-family Sq.Ft. � CROSS ST.C' N� �L= ��i Dat r v� � Applicant Residential Sw:mmirg Pools _ F�M NAME � 'Xt -'� - CERTIFICATE OF EXEMPTION FROM wORKERS' Mai� �}( C � t � � COMPENSATION INSURANCE �.- . Outlels:Rec_L'ght Frst�20 � � ADOFtE55 ��� `' � �f ��3 � (Thla sectba need not be rompletad M the work Invdved by the Total No. Addilional- - qTY_,L,i�\ Tel.No. permit Is for one hundred dollars(5100)w leas.) . � `� I certily Ihat in[he pertermance ot ihe twrk for which this permit f � � � - ����K � �y/�(�Q �/j��ll is issued,I shatl-noi employ arry person in any manner so as to t � become subject to the Workers'Compmsation Laws.... .:. L'ghting Fixtures Frs!20� � ---��- - ADDRESS �ZS�Q G. �jT -Ad�tional - . . . � .. . � � Total No. � qTY � � L �� � Tel.No� Date - Applicant Fzed Appliances Not Over t HP NOTICE TO APPLICANT: If, alter making-this Certificate of PERrai7 ��Q l Exemption,you should becomo subjeCt to the VJorkers'Compensatan Range_Heater_ D.W. _ A��' �" ��� LQ r provisions oF lhe Labor Coda,you must forthwith compiy with such Oven—Dryer_ W.M._ � ADORES � �.5 l�Ci ���� } pro:i;lons or lhis pennil shali be dcemed revoked. . . Top. _FAU._ W H.._ - �fTY a� y_�. � . G T�•�'�O�Z3� ' LJCENSED CONTFACTOf7S DECLARATION Hood—Fan _ Other_ �-' ��� I hereby altirm that I am litensed urder provisions oi Chapter 9 . uCENSE OR ..� (commencing wilh Section 7000)ot Division 3 0l the Business and -Disp. --F2oom Air Cpnd. — REG.NUMBER - � ��1z���� R'Ofe55i0n5 GOdB,afld R1y IiCen50 IS in fUll(OfC@ efi.j E(�PC1. DISTRIC�NO. PF70C SSED BY _ .Povrer ApPamtus 8 Large ADPliances .._ . . f) �e . ......__.._. }___.. /�� r f� � � Size 8 Type HP,KW,KVA,or KVAR . � I V '� p � License Number��Lic.CIasY�� . ._.. - . . .. . . .. . .. . . . . V Up to 1 Incl. FlNAL Over 1 to 101nC1. DATE /��) yALIDATION � Contrac�y��Dite�... . .. Over 10 to 50 Incl._ _ �i a� � U ❑ FlNAL I am exempt under ec. Ovzr 50 to 100 Inc. BY ///1 W B.dP.C.for this reason Over f00 ��" � , Services,Swbd.;MCC 8 PanelboarCs�" �- �- - - � � � - � ►� � -- - - - � - - - Z � - -�' Datef 0-200 Amp.Urder 600 V "4 0 5.5 A Signature "- 201=1000 Amp.Under 600 V " ��� " � � - -� -- -��� - � - �- - -� �� �� � � ��� Over 1000 Amp.or Over 600 V �� • • • e •2 Exemption for Reg,MainL Elect. ��� �� �� � ��SINGLE FAMILY � - � Temp.Rraer Pore 8 Appurfenances � ° •4 Q 5 0 � HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit ,(}71 U � � ° °��Q�5 Q� I hereby affirm tha[I am exempt from the Contracta's License Law , � for the followilg rexson(Seclion 7031.5,Busirress arW Professions - -�ditional Si9n Branch Cirwits .. .. . . - . I �� O�A� � Code): ❑ I,as owner oF the property,will do ihe work and the strucWre MisC:ConduNs 8 Conductors - - � - �� � - "�� -- � �� - is not intenAetl or oFlered for sale(Section 7044,Business Other(See Complete Fee Schedule)_ , and Professions Code�. �� � CONSTRUCTION LEN�ING AGENCY � � � � ' � � � � �- � - �- - � - � I hereby alfirm that there is a constnxtion lendir�9 ac,7ency 1or the performance of the work for whiCh this permit is issuc��Sec.3097, PERMfT FEE- - �� � - -ISub-Totaq - '�� � �- � � - � � Civ.C.). � /� � PLAN CHECKING FEE � ��-�-� �- �� � � � - , .. . ... _ _._ Lenders Name � . . PE(iMIT ISSUING FEE . - . . _ . _l O ..-. . - , . ... ._ - f Lender'S Atldress ' I certity that I have read thls zppiication and state that the above TOtAL FEE � ��Q .. ... ._... . . . .. . J intormation is correct.I agme to compy wi�h all Cwnty ordinances � aM Slate laws regu!ating Electrical wiring,and hereby authorire . . . . . . . __ .._ _ . _ . .. .. .. . . .� . . . . ___ representzti s 1 this mty to enter upon the a6a✓e-mentioned � ' � p_ ( 1 .ctiory� poses. � � - - � � � SEE REYERSE FOR EXPLANATORY LANGUAGE. .- . ..__ . _._ . �� . . k � � - Si ure en ittee Dat i t�;: . r�;.i;, • - , :�;_,.. ..._... .. . .. _ t.��� -- ' �' —I '-f _. ..,i.__;.__ ..f " �i: _: ;;: ,�;; , ', ; f: . .i i ; �, � L , i- j ��' � i (, � ''`� j ; �; ( '; ! i !' � '� . , � _ .. ,. ��� � �' , ��. ; . - �..' � - � � . , ' . _; -�� - � ��� - j.� , . �i•" , �"J i C' �' ! ; ' . ��,.�� _ � T '�� C ~ `' .. : � y-% '� Q .Z ^I. Q X L _0 Z m j�'f j . � '�\�N fD' -�-I Ri C 2 .� TSl ��. ^ r . . - I � , C1 q m � n r .C� �' i . � ! i. ''. 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