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HomeMy WebLinkAbout1373A - W9RKFRS'COMPENSATION DECLARAiION 76n6a3 io.'el A DD f '�A TI/'�� C�1p �'1 G/°"Ts�/"A t A�9�p!T tr� ) i i._._�,,, ;:rq..., ;;-...� : �..�..,.. .- ._.rlcate uf conseni ro seii __-.._� :.m a vT!ivs� i�J/� a."`.I IC�W�1Z �`�1�/YI11 � insu�e,o�n ce�tificare of worke�s'Co��ipensano����su�aoce, C(yUNTY O�LQ5 ANGELES BUILDING AND SAFEYY � or o certifiad copy rhoreof(Sxc.3800,lnb C.) ; Policy No._r��u�5�.j'¢�mpany z� FOR APpLICANi TO FILL IN ��UB $ ❑ cP�r�f�ed�o s t,o��b t����shed. EncH ,No. FEE �ooR�s Lot 8 `§Q9 LisaCour.t �y' Y New Residential Bldgs.&Pools s n 5 � iocaerv TR;f425$6 iiiamond Bar � Certifie.d mpy is filed�mith rhe:oun?y buiiding inspec- 1 8 2 Family,Sq.Ft �,[j.�}_(}�_�_ 4� lion departmenl. Moltidarnily Sq.ft._.____��_ NFAKEST y CRO55 Si. _' _ Q ; � Residential Swimming Pools OWNER OR � Date_,•�7(l��(-� (�pplicanfiT� 1��CPP �*.�P(`YYiC � !FiRMNAhSE �den Group � CERTI�ICAie OF EXEMP110N FRpM WORKERS' � � i MAu �� connaENsaT�oN iNsuaaNCF o�riers:�e�_u9�,�_sw._I noouess 1074 Park View Dr. P Thts section nead rtot be aom letcd if the work involved 6 First 20 �— + � P � Totol No. Addrtional c�rY Covina Ca. re� �J�i7-9541 the perrnit is for one hundrod dollars($100)or less.) �— PIAfV CHECK � I cer:ify!ha�ir,the perform�nce of the work fv�which�his � APPUCANT _ �_ • permi�is issued,1 shall not employ nny person m any monner ! so os�o become subjeci to ihe Workers'Compensation Lows. lighting FixNres Firsl 20 AUDRESS g Addilionol _ i_ Torol No. I —1� �CITY Tel.No. •. Appliconf_ Fized A lionces Nor Over 1 HP � . . PP I I f PiRMir ? — � :,���ICE TO APPLICANT: ff, af?er makina rh�s Cernfcafe nf � �'1'� i cGee F'ZECtr1C IriC. exemption, you should br.come wb{ect to ihe Workers' B 'APPLICAM7 __� r � Ran e�Heater_D.W. — � � I — Comoensalion provisions of the Labor Code,you must forth- Oven _Dryer _W.M._ I I I �AD�RESS P�(}� $0�:21.11. � with mmp�CFNSFD CON RACTpRS DfCLARATION Ho --�-FAU -.--W.H._ � ---'-��-�-�--""-"�-- with sech roviswns or !his ermit shall be dePmed�e�oked. od _Fa� _orhe,_. � I I I cirv Chino 91708 rei.No,591-6i61. ' � ----_ -------- tIC`NSE OR Class. N I hereby affirm fhai I am lirensed under provisiens of Chapter 9 Disp. —Room Air Cond. — � --�— REG.NUMdER �,, � icommencing with Section 7000)nf�rvision 3 of fhe Business p �� CISTRICT NO. �' PROCESSED 8Y 2. '{ ,ower P.pparotus&Lorge Applionces 1 :� cnd Professions Code,and my 6cense�s in fuil torce and effe<t. j /� qj,.- � � Sire&7ype HP,KW,KVA,or KVAR � L 490i�33 C-10 ----- --- c_ License Number__ Lic Clpss FINAL � Up la I Ind. I____'�- l} � Over 1 to 101nd. I y__��ATE `�./s„Q„� VA4IDATION lilectrica7. 8/20J8b r � '" e CoMradnr._ � _Dnte � FINAL -1 s --- - __ Over 10 50 50 Incl. L�____..__ . ? I am exempf und=r Se<.�_. Over S�o 1001nc I--�-"-�.. � BY '= p ❑ . . . _ _ � ..._.r—�— k B.&P.C.for rhis rens�n—,_..... . . �--}�-��-�-..-.-..-IC"- �--�--- rn [ ! � Seivites,Swbd.,MCC&Ponelboards � � i �""-`-� ---`�0��'— — 0-200 Amp.Under 600 V �_ # Sign�tu�e__— 201 -�Oi;O Amp.Under 6�V �' i ' � Over 1 WO Amp.or Over bOp Y � �-1�- � � Exemption for Reg.Main�.Eleci. � � � � ,. SWGiE PAMILY I � � 3 �s lemp.Power Pole 8 Appurtenances � �` � � ` HUN[OWNER-BUILDER DEC!ARpTION Sign with One Brnnch Circoit �—� _ �. �^ ' !' �Y I herehy affirm�ha�I om exempt from the Controctor's License ! taw for Ihe following r=o5on (Seciion 7037.5, Business ond Additionol Sign Bronch Circui�s � j,� t Professions Cade): ������ F Mlsc Conduits&Condudors � v. ; 4 � ' ' I,as owner of Ihe property,will do the work pnd�he J�:C U�• � structure is no�uvended or offered for sale (Saciion Oiher(See Complete Fee Schedule)_I � , `,,� ., ` 7044,Business and Proiessions Code�. -- � r%f% } CONSiRUC7ION LENDING AGENCY �— � i hereby affvm!hat�here is u censtn,cl��:on le,+diny agencY'er €p- ----- � rhe performanre of the work for which this pernut is issued 1 PERrAIT FEE (Sub-Totol) ! (Sec.3D97,Civ.C.). ! � PLAN CHECKING FEE � �P�ders Nam�__ aERMiT issuiNc FeE 1Q 50 � Lender's Address � I certdy Ihat I hove rrad this application and store Ihnt the TOTAL FEE �6 � above informaiion is co!recf.I oyree to comply with ail Counfy � nrdinonces and$tote lows regolotiny Electriml wirinq, and i� he.reby authorize represenratives of this County to en�er upon the ab ve-mentione oper'y 4or inspec�ion purposes. � SEE REVERSE FOR EXPLANATORY LANGUAGE � —� ° �"l�'R/zDaah i. Slynoivre o ermirtee Date �# ' . . ; . . , .�.. ' . , . ' . . . f i' 1, . � . . — . � . . � ' 4 � , i �.. ' . � ' � ,! . � .. ,. , �. : � . , ' � . i i . _ V � F . . _ >. .. i i , � � ' . . ! I ' -• _ . ... . � �i � � '. - , . - ` _ ` ` . � � . ; . �� � � . ; � , . , � � { � ' � �' � , ; � ', , i � �.� ; , , � �,� ' - i ' ; ; � ' . , �. '. � , . i `t ;� � , � � � � , , ; . � , . �5 , f ' ( �! . � . ' _ . i , � ' � � .... _�� �' . . '' . 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