HomeMy WebLinkAbout1043A WORKERS'COAIPENSATIONDECLARA7[ON .76A669 APPLICATION FOR ELECTRICAL PERMIT '
� , CE�806G(2�80) � (
l hereby aftirm that'[ heve a cm�iticate ot consent to selt COUNTY OF LOS ANGELES BUILDING AND SAPETY
insure,or a certifitate of Workers'Cnmpensatlon Insurance,or - � �
� a certified copy ihereof(Sec.3600.Lab.C.) ' �
� FOR APPLICANT TO FILL IN �pg �
No�icyNA `' �fYomPany- Comm LIniOA EACH NO. FEE ADORESS 1235 Diamond Bar B�.Vd.
- New Residential Bldgs.&Poots �
� Certified copy is hereby furnished. 1&2•Family,Sq.Ft. $ — S LOCALITV
� Certified co is filed with the county buildin p Multi•family Sq.Ft. NEA 57 .
py g ins ection Residential Swimming Pools C1io55 ST
Jepartment. . � OWNER OR
FIRM NAME
Date ApPlicant Outlets:Rec._.Light�Sw._ A��
F;,S,�o -�� /6 Z ADDFiESS 363 San Miguel, Suite
CERTIFICATCOFFXEMPTIONFROMWO[LKERS' TotalNo.� Additional Ci7vjJeW OLt Beachr•�NQ.7141759-01 �
-COMPENSATION 1NSURANCF �
� PLAN CNECK a
APPLICANT O
� (This section need not be complefed if the wotk involved _"7S- 2tl U
by the permi[ is fa one hundred dollus (5100)or less.) �'9htingFixtures First20 ADDRESS
Total No.� Additional •� �
�i cerfiCy that in the performanae ot the work for which ih15 CI7v Tel No. �
Fixed Appliances Not Over 1 HP
:permit is issued,1 shall nnt employ any person in any manner PERMI7 �
so ss tn Aecome su6ject to the Workers'Compensation Laws. Range_Heeter_D.W._ APpLICANT C & H Eleetrie COIII an d
Oven _Dryer_W.M._ ADORESS �
2
4ate �ppiicani � �op _PAU _W.H._ � CITY GYanada Hi11�a�No. 360-4508
- Hood_Fen _Other_
NOTICE TO APNGICANT:]f,after making thls Certificate ot Disp. _Room A1r Cond._ � ��CENSE O �
Exemption, you s0ouid 6ecnme subject to the Workers' REG.NUMBER - Cla�s _ .
Compensatton pmvisions ut the Labor Code,you must forth- power Apparatus&Large Appliances � �ISTRICT No. PROCESSED 6V
with comply wifh such provisions or [his permit shall 6e Siie&Type HP,KW,KVA,of KVA 1� / � i ' �'�" .
deemed revnked. � 17 �Y���
Up co 1 Incl.
Over 1 to 10 Incl. ppTEL I -
LICENS[�CONTHACTORS 0@CLARATION � Over 10 ro 501nc1. �,� l� V VALIDATION
1 heTeby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. FINAL �
9V
9(commrndng with SecHon 7000)nf Division 3 of the Rusi• Over 100
ness and 1'rofessions Code,and my ticense is in full force and _ ,
ef(ect. � ' $ervices � - � � ���C
�� 0�200 Amp.Under 600 V dt1. ��(l . �
LicrnseNumber -� 454 iaClass C-1� �j�.��qmp.Under800V ' .
�Contractof' `u tT R�ac-t�,� - 1/16/84 Ove�7000Amp.orOver600V �`-�S�i„`� .
HOStE OR'NGR•BUILDER DECLr�RATION Temp.Power Pole&Appurtenances � '0 � '� �1 0 4 3 A ,
• �. . . . .2
1 hereAy affirm that 1 am exempt from the ConhactoPs � Sign with One 9ranth Circuit . �
License Law!or the following reason (Section 703I.5,�Buci•� Additional Sign Branch Circuits I • �7 Q�5 Q
ness and Professions Code): ' . , � ' o � � q��r�� '
� 1,as owner of 1he property,will do the wark ond the Miu.Conduits&�ConAuctms �!� Fj
structure is not intended or otfered (or sete (Section Other(See Com lete Fee Schedulel—
7044,Business and Professions Code). j
" CONSTNUCTION LGNDWC AC3GNCY�
1 hereby aftirm Ihat there is a cunstmction lending agency
for �he performance of the work for which this permit is pERMIT FEE � (Sub•Total)
Issued(Sec.7097,CiV.CJ. �
L�nder's Name PLAN CHECKING FEE (One•fourth Permit Fee) �
LenJec's Address pERMIT ISSUING FEE �/� �
i ttrti[y that I have read this 3pplication and state tfiat the TOTAL FEE 17 � �
aAove intormation ia correct.1 agree to camply wlth alI Co�mty '
ordinances and State la.�s reguiating Electrical wir(ng, md � ' . �
hereby authorize representalives of t Counry to enter upnn � .
the ba e-me ione propslYy{or in eqtion purposex. � �
�} SEF,'RBVERSL•1'OR F.XNLANATORY LANGUAGE
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Signeturc f Permittee � a[e . . . '
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