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HomeMy WebLinkAbout0769A ' WORKERS'C9MPENSATION DECLARATION ��� ��.a� APPLICATIQN FOR ELECTRICAL PERMIT � � I hereby ofinm tho�I ha�e o cenif,cn�e o!co�sen+io sell �-� insuro.or a cern(�coie of wo�ke�i Compe�sai�o��.+swo�ce, Cp�y Txn F Lf�b�GElES BU�LCIING AND SAFETY o�a ce������d coor�Hereo��Sec.�e0o,�nb C. TR,N3$S65 LOT 25`! Y13[I voue,���)RCS13990�om��v Roya� 1ns. rw�mic�rarorx�iM x�e � Cer�ihed co �s htlrob ��rnithed EACH NO. FEE ADORESS pt py� y New Re�idenYalBldgs.d Pooh rG1 Id7�fom�i F�, s _ f ����Ty Diamond Bar l:J Cen�Ged coDv is filed w��h the coumy build�ng inapec. Y,59� -�--�� Mulli.�pmil FI. NEARfSI . Yon deponmM�. Y 59� caOSs St. �+ � N ��yQ� Residenlial SwiMming Poolt OWrvER OR pplp � / �APpIiGOn . FIRM NAME CERTffICATE OF EXEMPTI FROM WORKERS" O�tle+s:Rec�l�gh���Sw.� � ��� COMPENSATION INSURANCE AODRFSS F�rs�20 (This��Nion n��d nof b�compl�l�d I(fh��vofk Inrolwd by To�ol Na. Add+�;onal CIN • • Ox Se1.No. IM p�rmN 6 io�on�hundr�d de4lart(SI06)er I��s.) RAN CNfCK � 1 ce�iily tho�in Ihe per(wmonce oF Ihe wo�4 fo�wh�ch Ihis ' AvvIIGaNT 967-9541 pe.mil is issued,I sholl not emp�oy ony person in ony monner � to os to become�ubjec��o�hv Wa4e.s'Compenwho�Laws. L+9hiing fi��uros Firs�ZO ADDRESS ^ Addi�ionol Totol No. CITY Tel.No. � °PP��<°^� fi�ed Applionces NotOver I HP PERMIi NvACE TO APPIICANi: li, o0er makfng�his CeniGca�e o( APoi�(J�M SUPERIOR TEMP POWER ELEC CO . Ezempiion, you should become subject to ihe Worke�i Ronge�.Heoter�D.W._ Compenwron pro�fsons o4�he labo�Cede,you mus�forlh- Oven �Dryer _W.M.— ADDRE55 A Divi 510[t O f1 u5 [12 �� wiih eomply wirh �vch provislons w �hif pe�mii aholl be 7ap �fAU _W.H.-- • deemed revoked. Hood �.Fan _Oihe�_ ��ry Tef.No. _ S3 UCENSED CONTRACTORS DECV�RATION UCftiSF OR � 1 heroby olfhm ihoi I am Hcensed unde.po�lvens of Chap�e/9 Drsp. �Room AI.Cond. — REG NVMBER 48312 5 Closs.C-10 n' (commenc�ng wiih Sen�on 7000)of Diuia�on 3 of�he Business power Appo�arus 8 la�ge Appllences DISTRICT NO. PROGESSED 9Y O ond Frofessions Code,o�d my licenu is in f�ll force ond aftect. . � v S�:e 8 TYPe H�,KW.KVA.or KVAR � U 4celse N�mber J Uc.p ss� FINAL a � A^ Up�0 1 Incl. pATE d f � �C ' -_-� O.er 1�o 101n<I. ���Z(o"��, VAUDATiON � � Contr doI '� Doie O�er 10�o SO IncL . O f�NAI � I om eRem p�ynde.Sec. Oyer SO l0 100 Inc. BY � 0. N � 0.8P.C.(o�Ihis recson O.er IOD - Z � �1e. Serrices,Swbd.,MCC 6 Panelbovrds ► � � 0-200 Amp.Undm 600 V $igrwwrQ 201-1000 Amp.Unde�600 V ��7 Q 9{� ❑ Ovs�1000 Amp.o�O�er 600 V E.emption for Reg.Maim.Eleci. �'� �' ��2 �', SINGLE FAMqY Temp,Powm Vole d Appvrrenoncas � I • {��•9 O � HOME OWNER�BU1lDER DECLARATION 5;9�w��h One Bronch��rc��� _ � 1 hereby affi�m thot 1 om eaemp�from�he Conirocio�s license Add��iionol$gn 9ranch Circuin � •• �b Z 9 0� I lpw for Ihe following reason(Seeeion 703L5,B�siness pnd P,ore.:,o�,��a,� o a t a—a b ' ❑ 1,os ownar of ihe property,will do Ihe work ond Ihe Misa Condui�e 8 Conducior� � s�roau.e�s no���iended or o�fered!o�sale(Sect�o� O�her�See Compleie Fse Schedule)_ ► � 704d,Business ond Prolass�ons Code). CONSTRUQ[ON LENDING AGENCY , I hereby olflrm�hp��he.e is a<onsvucrion lend�ng pgenq(or . Ihe perfo�monce o(Ihe wo�k fo�which�h�s permi�is issued FERMIT FEE � (Sub-io�al) '� (Sec.3097.Cir.C.). . PIAN CH[CKING FEE . lender's Nomew , PERMIT ISSUING FEE � � ' lender i Addreu , I certily Ihoi I have reod fhis oppl�co7ion ond s�o�e�ho��he TOTAL fEE � 1�7.9 obove in(amoNon is carec�.I eqree to eomply wuh oll Counry ordlnonces ond Sraie lows requ�o��ng E�ecn�col w�r�ng,cnd �, hersby o��honre reprosenio�ives oi ihn Coun�y b emer upon the obove�me���oned p� .ny�o�inspec�ion purpo s. �� SEE REVERSE POR EXPIANATORY LANGWGE � CJ�?C.��'.G � � �re of Peim�rt Do�e � - - . . ,_ . .. , r'. �i F �, � ,.', � , 'I'. . ; ' '. 1 .I', , � { , ____...--- --- ----- � , 1 - ^ � :^-- � .. .. V BVqDER CCC:A'nATIOTJ , . Arerovnts �nnTE � �_Q 1NE2- � . � - - - SIGI�A7URF � � - --- -�-� -� --- "�- � � TEMP_�pOWE4 P�IE. - � - � ' � ��`-�j I fiero6y o��um•h�r I om wxn�d!�om�hn Co���ac�o�'s . . ,_ _ �_ __ - . . � � . . Licnnso low fw �he following reo;an (SocGan 703�.5. � -� - ��-"" ""-� �-� UKDEFSLA9WOnK � - �� , I CusinestandProfesslonsCodo?.Any�ilyorrouMywhich - -� - - ROUGH CONGVII - � .. ���� •. ` . . �aquires a pormi!lo mnsbucf,oller,Imorove.�domolish. 1 ._. . . _... ..". . ' . � q�rapal�any alruciurc,prfor fo Ih Is+uon<e.olso re• � WIR�NG- � � - �O+l$�-g� I�f.� . � -. u�roelfieopFl;cavlar�ucbpermueoY�oo��gneds!ato- . , �__._ .. .._.. .. � ._ . _ - f!XTUFES .. - � ;- � . � � , menf fhaf he�a Ilrcmed pvnuonl fo fho provlslpns ol/he ... ._ . � �.ContraHori Ue�ns�Law(Chapror 9(mmmoneing wl�h . . . ` ' GOWER AUT}iORIZ:O . . - ..' -. _.-. .. , . _. -.. '•... � , '�:�Sarhon TPOOj of Oroision 7 of Iho Bus+nast end��of�a� ?� � � UTIIITY CO.NOTIFIED , . sions CodeJ or tho�ho is oanmp��horalrom ond�ho 6asn _ . _ .. c7 lor fho.ollaged oxemptlort. Any vlolorion ol SeUio� FINAI ���(�.on .iron['..�. . .. . _ , . . . ... � . 7037.5 by any oppllcont for a permit�ubjocre ehe oppb� - � - � � - . . . � son�fo o clvll penolfy ol not mora Ihon livo hun�iad ' � NOTFS � � �� . •, doFlars(SSOD).: "t . � - � ' �" . . - .. .. . ' ' � � [;1,os owner of Ihe propc�iy w,ll do�i,e wwk. ..x1 ine e�r�cwea�s not irt�endod or oiferod foi so�e. � . . � . � . . �� . __ . .. .._ . . . (Ssc.7041.�usine�sandPro(x�fwns Codu: ih�Conrrot� 1 ' � lor'c Uc�nie low dooa oo�opply fo on ormer o/propwrty . .. . .. . . ' � , . „ , , whn bullds or'Improres Ihereon, ond wbo dost fuch � � - � - - "-" -" work hlmsvlf proWdod fhu(sutA�mprovemmts ore nor .- . . .- . .... . � . .. -.. --._!-. .---�-- � --- - � - ' ' . :nrendkd or otfarod Inr sale 11.however,�hs bvdd�ng or � "�""'-� -'-�''-�� �-� �� � �� ' - � � �mprovan:ant is aoid wi�hln one yeor o7 complehon_�he �. . . � •owner-bu�fdor wtll hove Iha 6urdnn el provin�Ihor Ae d�d - � � •no�bulfd or improvo br�ho Aurpo+�o!safe.) : _ , . . . � .._ _ . � � - . . - . , _ . _- .. _-. -., .I am eaempt undar S�-'` ' . . ._ . _ . . . . _._ . - . - . ..--. ..__. . � . �� . . . . - ' ` . �. ' B 8 P.C..for r6,rcosan .. . ...!, . ;. . : t _: � . _ . . , . ._. __. .. .� � .__.,_. _ i .. . ... . .._ . .--� --� . . .., � .. uafoT . i • . . . , , Owner ' . . , . , . � ,_,,,, � _ . . .... ._ __ _._ . , .... , � . , . � . .. . . ._ . .. _._ . . , . . . . ,,. _ ._. _ :_._ ._ _ � - � � i � .. � . . . . . . . ' . ,. . . . . . . .. . .. �. , j � .. -- i , ; - • - _. : ___ __ _ i . .__ .. . _ _ - . . __ ._ .. �