HomeMy WebLinkAbout1000A (7) WORKERS'COMPENSATION DECIARATION 76n663 �Oiel qpp�ICATION F �h CAL PERMIT �
I hereby oflirm iha� I have a ceriifim�e of consent�o self CE-Bo6G �
insure,or d cenfflm�e of Workers'Compensoiion Insurance, COUNTY OF LOS ANGELE v UILDING AND SAFETY
or a cert�fied copy thereof(Sec.3800,Lob.C.) ' TRAC #43 12
Policy No. I�Eompony STATE FUND FOR APPIICANT TO FILL IN !O
[�] Certi�ie coPy is hereby furnished. EACH NO. DRESS 448 N. GOLDEN SPRINGS
New Resfdenlial Bldgs.8 Pools
� Certiiied copy is filed with�he co�nty building inspec- 1 8 2-Fomily,Sq.FL 5 — E �ocaurrUNITS 22-28/DIAMOND BAR
tion deparrmenr. Mul�f-famfly Sq.F. Y�� — NEAReSi
Do�e 8�8�86 � �Resldentiol5wimmin Pools CROSSST.
nPPu�am—AAINBOW ELECTRIC 9 pWNEROR
� FIRM NAME '�E ANDEN GROUP
"�CERTIFICATE OF EXEMPTION FROM WORKERS' Outlels:Rec 7 lighl 7 Sw.7 •75 z iS�OO Mqil
' COMPENSATION INSURANCE ADDRESS P.O. BOX 33
(Thl�a�ctien nNd nof be complal�d if tha work invoiv�d by First ZO
io�al No.�_ Additional CITY Tel.No.9(�] 9S�t1
Iha permil ls for o�s h�ndr�d dollor�(S1D0)er Isf+.) PLAN CHECK
I cer�ify rhot in Ihe performance of rhe work for which this APPIICANT �
permil is issued,I sholl not employ any person in any manner ,
so as to become subject lo the Workers'Compensa�ion laws. lighiing Fixtures First 20 •75 7 5 25 ADORESS
iorol No._� Addiiionol i
CITY Tel.No.
pplicanl Fi.ed Applionces Nat Over 1 HP pER,yuT
h.,�CE TO APPLICANT: If, affer making this Cerli(ica�a of APr��cnr,BAINBOW ELECTRIC LTD.
Ezemp�ion, you should become su6ject to the Workeri Range_Heote�—D.W._
Campensation provisions of 1he lobor Code,you must forlh- Oven _Dryer _W.M._ ADDRESSSI�F B. .5�. LEMON ST.
with compiy wilh such provisions or this permit shall be Top _FAU _W.H._
deemed revoked. Hood _Fon _Olher_ CITY FULLERTON rai.No. 992
LICENSED CONTRACi0R5 DECLARATION IICENSE OR
1 hereby af(irm�ha�I am litensed under provisions of Chapter 9 Disp. _Room Air Cond. — REG.NUMBER Class(�'_10
DISTRICT NO. PROCESSED BY }
(commencing wiih Sec�ion 7000)of Division 3 of Ihe Business power Apporat�s 8 targe Applivnces /O � O .
ond Professions Code,and my license is in i�ll force ond effec�. � U
�����a Size 8 Type HP,KW,KVA,or KVAR�
License Number lic.Closs r-1� Up to 1 Incl. FINAL C�
398621 8�8�86 o�a.i ro IO lncl. • DATE �p ��/g� VAItCAT10N �
ContraUor_ DA7AR/1W FT.R(:T��' Orer 10 to 50 Ind. W
� FINAL
I am exempt under Sec. Over 50�0 100 Inc. BY p.'
Over 100 N
B.SP,C.for this reosan Z
Dote• Services,Swbd.,MCC 8 Ponelboards � —
' 0-2b0 Amp.lJnder 600 V
$ignature 201-1000 Amp.Under bQ0 V
OOver 1000 Amp.or Over 600 V :'� Q Q�A
Exemption for Reg.Maint.Elect.
� SINGLE FAMILY Tem Power Pole 8 A �•� • e e 2
p. ppu�lenances
HOME OWNER-BUILDER DECLARATION Sign wirh One Branch Circuit � � •3 4 b 8 1
I hereby affirm�hat I am ezempl from the Conhocror's License Add�Gonol Sign Branch Circuils � ' -"�
law for the follawing reason(SeUion 7031.5, Business ond • e�4�,a,� �
Professions Code): .
� Misc.Conduiis 8 Cond�ctors �
1,as owner of the property,will do ihe work ond the 0'���'8 6
strucWre is not inlended or offeied ior sole(SeUion O�her(See Complete Fee ScheduleJ_ , .
704E,Business and Professionz Code).
CONSiRUCT10N 1EN01NG AGENCY
I hereby aifirm iha�there is o cons�ruction lending agency for
the performance of�he work for which�his permi�is issued PERMIT FEE � (S�b•Totol) 33b 31 �
(Sec.3097,Civ.C.). ,
PLAN CHECKiNG FEE
lender's Name
PERMIT ISSUING FEE LO SO
lender's Addrezs
I cr.rtiFy thal I hove read Ihis application and s�ate thot the TOTAI FEE 346.81
obove informat�on is correct.I agree�o comply with all Counry
ordinances ond S�aie lows regulating Electrical wiring,and .
hereby ovthorize represen�afives of this Co�nty�o enier upon
ihe above-mennoned properr for inspetrion purposes. SEE REVERSE FOR E%PLANATORY LANGUAGE
8/8/86
Signa�ure C Permittee Date .
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