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HomeMy WebLinkAbout0859A WORKERS'COh7YEN5AT[ONDEeLARATION � � 76A663 qpp��CAT10N FOR ELECTRICAL PERMIT �. � CE-806G(2-801 I hereby afFirm thxt i ha�-e a �ertificate.�of consent tu self COUNTY OF LOS ANGELES BUILOING AND SAPETY ��, insure,or a certificate oF Wurkers'CompensaYion Insurance,or - � - . - a cerNfied copy tliereof(Sec.3800,Lah.C.) � �i, Policyl+�All1��rAAlC�ompany F4FMllNT TTiP1F.MNT. FORAPPLICANTTOFILLIN - �pg . . . � � . � NewResidential�Bldgs.&Pools - EACH NO. FEE A��RESS � ❑ Certified cupY is hereby furnished, 1&2-Family,sq.Ft. � — $ �ocA�iT� DIAMOND BAR � ^ - - - ,���� Multi-family Sq.Fi. NEAREST j�� Certified wpy is f�led t�tth[I�e eounty bui�rdfng insp ction q� CROSS ST 2� depar ment.� '' '' Resideniial Swimming Pools -� d t„�L';� _ �` , OWNEROR P .+' �"� FIRM NAME LIS �.3 �� pp �����'� �'���fA���,��� Outlets:Rec._L�4 ht_Sw. MAIL - Date A 1 c�e� 9 First 2D ADDRE85 3�-77� HP'WKW�OD - � CE"TIkICATL.OP-EXEMPTION-FRONf WURK}SRS' �Total No. Additional �--CITY - -� Tel No �. COMYENSATIONINSUR:INCE D� N AR- 5 �-42�7 } , . . . � APPNICAiVTk ��+�UT POOLS � (This' section need qoC �be com leted.if the woik involved Lighting Fixtures First 20 - � � l�y�tlie permit is for onc I�und�red aoua�s ($100) or less.) . aooREss � � Total No. Additional - � 21�50 GOLDEN SPRI1�tGS � I certiFy that-in the peiformance of the work�for which this � CITY�A�NU7.' Tel No595-7547 � -permit is isaued,T shall nu[employ any person in any manner Fixed ApplianCes Not Over 1 HP . , PERMIT � so as to Uecome subject to the Wmkers'Compensation Laws. Range_Heater_D.W._ � APPLICANT� w N T .PQOLS- a oven _oryer_w.nn._ atsoaess 21450 GOLDEN SFRINGS � Date � .Applicant - Top _FAU _W.H.._ . . . . .� � � Hood_Fan _Other— CITY WAL UT Tel Nor�95-7547 � � NOTICE TO APPLICANT:If,after making this Certificate of .Disp. _Room Air Cond._ LICENSE OP � � �Exemption, �you should become subject to the Workers' REG NUMBER 319�01g. Class 53 � Cumpensation provisions of the�L�abor Codc,you�nust fbr[h- - power Apparatus&large Appliances DISTRICT NO. PFOCESSEp BV � � with comply �vith such provisions or this permit shall be � � . deemed revoked. � � Size&Type HP,KW,I<VA,or KVAR > � � � � � . . Up to 1 Incl. � � J r�' �d�'�'A - Over 7 to 101nc1. . PINAL . � � � � L[CENSED CONTRACTORS DECLARATION DATE y VALIDATION � � . � . - Over 10 to 50-Incl. �j.' ("'"���.- � �I hercby affirm tliat I am licensed under provisions of Chapter Over 50 to 100 Inc: FINAL - � � 9 (commencing with 3ecCion 7000�of Division 3 of the Busi- Over 100 8 � � - � ness.and Professions.Code,and-my license�is�in full�i�orce and � � . ettect � - � Services - - - �� ' �l�''+ � �"'' 0-200 Amp.Vnder 600 V . - - � .License Numh �c.Cless . 201-1000 Amp.Under 600 V Contracto�?`��_,���ate_/l�""4`J�'�� Over 1000 Amp.or Over 600 V � . - -HOME OWN�R-BUILDER DECLARAT[ON Temp.Powcr Pole&Appurtenances � ' � I hereby uffirm that 1 em excmpt Yrnm the-Contractor's Sign with One Branch Circuit � License Luw for the following reasnn (Section.7031.5, Busi- Additional Sign Branch Circuits . � . �(���(�� . . ness�nd Profession�Code): �� � - � � � � � - Misc.Conduits&Conductors � � r�� ���e �•�� � � 1, as owner of the property,will do tlte�vork and the Other(See Complete Fee Scfiedule)— � � �. � atructurn is not intended_or offered tbr sale (Secfiun . . � � .f � ,J��.5(j . � � 7044,8uxinesn and Professions Code). � � � � � .� CONSTKUCT-10N LEP1ll1NG P.G;ENCY , . a �,-a�y c��,r...,, I bereby ufPirm thuY there is a cm�xtcuctiort lending egency � � for the performance of the �vork for which [his perinit is pERMIT FEE (Suh-Total) � , I i3��,'��'"����Y )ssued(Sec.3097,Civ.C.). . ({'(,� - .- � � Lender's Name � P�AN CHECKING FEE (One-Fourth Permit Fee) . - [,ender's Address PERMiT ISSUING FEE . . �/"- .� _ � --I certiFy thaC I have read Chis uppLication nnd state tliat the TOTAL FEE d� � � � � - �above infonnaiion is correct.[xgree to comply with all County � - � � -oedinanceg-M�nd State luws regulaCiog lilectrical wiring, and - - _ - � . hereby e}jkhorize�cesentativea oP tfiis County to enter upon - � � ' � � t¢c,�U;'��e-menNypfred property fbc inspection purp ses , . � � � � � ,�' ,� SEF;'NEVERSL POR EXPLANATORY LANGUAGE d;�� 4�'�� �a s.r&�---'" (I Oq� �"� ,��.Ssg a'fure uf Permittee� � aYe � ', � . � _� .. � . . " . .. . .. . . _. . tv�"d..� . ,i � � . . . .. . . a�C,.�q'� . 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