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1180 S DIAMOND BAR BLVD (19)
l � �E-$06��2-�0, APPUCATION FOR ELECTRI�AL PER�MIT � ,-WORKERS'COMPENSATION�DECIARATION 76A663 � � . � �erehy affirm that I have a certificate of cunsent to se�e�1 COUNTY OF LUS ANGELES BUILD.ING AND SAFET �.�insure,or a certificxte of Workers'Compensatinn]nsu�ance,or,:,; . � � � - . ."i , �`a certified copy thereof(Sec.3800,Lab.C.) � ,��,` �� � � `� 'J-G�'r��l�' f� FOR APPLICANT TO FILL IN �JOB � U ' y� �YolicyNo��,'�y ComP�nY�a�/4�/�ItS .E�i'��. ..� EACH NO. FEE ADORESS � . . � New Residential Bldgs.&Pools -.i'�`�Certified copy is hereby fumished. t&2-Family,Sq.Ft. g — � LOCALITY �� �� � '❑ ," Muiti-famity Sq.Ft. — NEAREST � Q �Certified copy is filed with the cuunty building inspection,,i CFOSS ST department.' � ,: Residential Swimming Pools , OWNER OR ;.�Uate�� ���`�APPlicant��'�/�f'�`�✓�L���!"'�'G�� p � FIRN NAME � . . q Outlets:FlecjZ/Lic�ht�8, Sw. 3�" /@ G� qDDRESS . � �/'n Fust 20 � CERTIFICATE OP EXIiMYTIUPI FROM WORKI�.RS'-�. � Total No.�� Additional ����p��GTY - Tel No. p - CUMPlNSATION[NSURANCL•: � J� , � -. PLAN CHEC f � ���� �"(TLis secrion need not be completed if the woxk invoived '- - .�iD . �t /O� OD APP��CANr� �,� . -'by tlie permit is frn one hundred dollaes ($100)or less.) �' �'9hting Fixtures n First 20 p qpoaess � � . . � �.�G�.�� Additional •� p � � Total No. � �I certify that in the performance of the work for which this /"��� 1�� CITY Tel No. � ' � Fixed Appliances Not Over 7 HP f„) �:,'permit is issued,!shull not employ vny person in uny manner �� . � PERMIT '.W � �so aa to become suUject to the Workers'Compensation Laws. E: Range_Heater D.W. APPLICANT t'.�!h� L��L'��r'E'/fi., „� � � � �� Oven _Dryer_W.M._ ADDRESS �.' . ( ' � .Z�lC'. OC i%���f' .2� �.. �Datc A lican[ ! Top —.FAU _W.H.._. . t/ �� PP � CITY Tet Nb.'.�. � Hood—Fen —Other_ . I �,�!4/�t'`� ��i�-/�Z � . ����NOT[CE TO APPWCANT:If,aYter making thix Certi�cxte��f �� Disp. _Room Air Cond._. LICENSE OR p a � � �9�.xemption, you should become subject to the Workers' 9y ��, REG.Nl1MBER �Jzf�.x�� Class �..-� L� �:Compensation provisions uf'the Labor Code,you must forth- ¢.r ppyygr Apparatus&Large Appiiances � DISTRICT NO. PROCE5SED BY '� ���with com�ly with such provisions nr [hiF petmit shell be j� Size&T � � , ype HP,KW,KVA,or KVAR �.deemed revnked. t;{ /��,� L�`�L*-� .-� f �. � . � . V3 7 I up to��nc�. ?_•5�D .�l% � ''"_ . . i 3 I Over 1 to 70 Incl. ��� 15� va oATe � LICENSED CONTRACTURS DLSCLARATION 5� � �pver�10 to 50 incl. ' � � �-� VALIDATION� � .1 hereby affirm that I am licensed under provisions of'Chapter �, Over 50 to 100 Inc. gY AL � i. 9 (commencing with Section 7000)of_D��'isinn 3 nf the Rusi- � � .Over T00 � . '-2�.-✓"`-� 1 .ness and 1'rofessione.Code,and my-license is in full force anJ {� �effect. . . "� Services . ' � � �,[�f�r��`+ �?..^/C S� D-200 Amp:Under600 V License Number Lic.Class �y y� /�7 � 207-1000 Amp.Under 60D V ��C�r��r�.�-��L'�I�-/� Date /aT^ ��d'� = Over 1000 Amp.or Over 600 V 5d•�� 50 OQ � �J I ; f HOMP.OWNER-BUILDER DECLARAT[ON f Temp.Power Pole&Appurtenances ' 4, ,� lO.� �;"a taC9 �'O�/'I � # &gn wV'aOJe Branch Circwt � � I herebv affinn [hat I am exemui from the�L'ontractor's � . .. � License I.aw for the following reason (Sec[ion 7031.5, Busi- � , �y�f1°"�"�"�"' � ::::� _ �1 . � ness and Profesaione Code): �3, �Y' �, , , � ' � .�' �x Misc.Conduits&Conductors ; � � � 1, as uwner�of the property,wilJ do the wock and ihe �� pther(See Complete Fee Schedule)— ,-F structure is not intended or offered for sale (Section ,y - �. ��. .:(�(j � . 7044,BusinessandProfessionsCode). nt CONSTI2UCTION�LtifQUIMG AGF.NCY' --�.����-� _i� �-i�F /..(�?; � � I here6y ufiinn tha[�[here is�a construction IendiiiK xBency {� ��� for the performance of[he work for which this�.permit is ��� .L- ( issued(Sec.3097,Civ.C.). � ' PERMIT FEE (Sub-ToWl1 � t�u �� `c':1 �r E�t; Lender's Name -- �, PLAN CHECKING FEE (One-Faurth Permit Fee) � l,enders Address' � � pERMIT ISSUWG FEE � p�' � � I certify th�t 1 have read this application and state that the � TOTAL FEE -�� _ /�i„ above infurmation.is correct.I agree[o comply with all Co�mty — � � ordinances and State laws regulating Electrical wiring, xnd ,�� � . � - here6y authorize represerttatives of this County�to enter upon . . . the allove-mentiuned D*�Perty for inspection purposes. .��' SEE�REVERSE FOR EXPLANATORY LANGiJAGR � � I�o,.w�'C"�".' ,�,�✓�-2- �',�--/6__�, �' , Signature of Permittee llate � ` i � j � � � � ��. . � I � � : � � . . . i , . � .l � _ ; ( .�� 1. . 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