HomeMy WebLinkAbout1375A (7) � WORKERS'COMPENSATION DECLARATION �bn66s i0iet APPtICe4TIOM FQFt ELECTRICA! PERMIT �
I hereby aff�rm that�have a ceriificaie of consem ro se�f `E"�
� insure,or a certificate of Wo.kers'Compensa��on Insurance, COUNTY Of LOS ANGELES BUILDING AN�SAFETY
or o certified copy fiereof(Sec.3800,Lab.C.)
Pool��ty No.C258595��ompany I� FOR A�PLICANT TO f EA H Np. �E DDRES Lot 10 � 0 Lisa CiOt1Yt
Certified copy is hereby fumished. New Residenrial Bldgs.8 Poo1s �p�q�� Tg�42586 iamond Bar
I 8 2-Fomil Fe. 1 S�j3 a — E
-� Cerf'rfied copy is filed w�lh ihe toonty building inspeo- Y•�9' _ NEAREST
-- tiondepartment: - Muiti-family5q.Ft CRO5557.
$�2��86 ��T�� McGee Electric Res�dential Swimming Pools OWNEROR
Dole ApplicoN FIRM NAME At►dea G
} CERTIFICATE Of EXEMPTION FROM WORKfRS' Outlels:Rec_light_Sw._ qDo�RE55
� COMPENSATION INSURANCE First 20
� (Thls+�eNvn need not b�rnmpfeNd i}!hs woAc inwlvad by Total No. Additionol CITY �vina CR. Tel.Na�67-9$Gl
3 th�permi�i�for one hund�ed delbrs(5�00)er las+.} PIAN CHE[K
4 1 certify that in Ihe performance of ihe work tor which Ihis AGMICArvT
} parmit is�ssued,1 shall no�employ ony person in ony manner
so os io become subjec�ro�he Worke�s'Comprnsation lows. Lighting Fi:torea First 20 ADDRE55
i Addi�ional
� . Torol No. CITY Tel.No.
� � PP���o^� Fixed App�iances Not Over 1 HP PERMIT
� Po.,,CE TO APPIICANT: If, ofier making this Cerlificpte of APPIIUNT ��T�� ��e Electric, LIIC.
' Ezemption, you should become subject io the Workers' Range_Hearer_O.W._
� Compernation provisions of the iobor Codc,you must Forth- Oven _Dryer _W.M.� A9DRE55 IJ�Q� $pX 1111
� with comply with 5uch provisions or �his permit sholl be Top _FAU —W�H.— C�TY Chino 91708 7e1�N°591-6461
deemed revoked. Hood _Fon �O�her,
a LICENSED CONTRACTORS DEQHRATION uGENSe OR
$ Disp. _Room Air Cond. — REG.NUMBER 490083 Class. C—IO
= I hereby affirm tFwt 1 am licensed onder provisiom of Chopter 4
(commencing with Section 70pp)of Division 3 of the Business power Apparotus&large Appliantes DISTRICT NO. � PROCESSED BY a'
� and Professio�e Code,and my license is in full force and eHec�. Z� (�j
} Size 8 Type HP,KW,KVA,or KVAR
{ licanse Number 490QR'� Lic.Class C-70 Up ta 1 Ind. FINAL �
r Over 1 to 10 Ind. DATE �y��r„�� y aT10N U
� connaca� Elect=1ca1 pare 8/20�86 �
`i Over 10 ro 50 Ind. FiNAL a
, ❑ 1 am ezempt under Sec Over 50�0 100�nc. BY Z
� B.BP.C.for tMis reoson Over 100
M �'e Serv�ces,5wbd.,MCC&Faneiboards �
0-200 Amp.llnder 600 V
S�gnarure 201-100D Amp.Under 600 V
� � Over l OW Amp.or Over 600 V <� �(,,�i h�,
Exemplion for Reg.Moi�t.Elett.
� � SINGIE FAMIIY Tem Powet Pole 8 A �`� � � � �2
p, ppurtenonces
HOME OWNER-BUILDER DECLARATION Sign with One Brafrch Circuit � s a'��j,�j 2
I hereby offirm ihot I om exempt from the Coni�actor's License qdditional Sign 8ra�ch Circuits
� Law for the following reason(Section 7031.5, Business and
i Professions Code): * - � r'�"C��
� ❑ i,as owner of the ro er will do the work and the Misc Conduits 8 Conductors
P P �' Othe�(See Complete Fee Sched�le�_ � �}�'Z�'8 6
� siructure is not in�anded or offered for saia(Sedion
I 7044,8usiness and Professions Code).
( CONS7Rl1CTION LENDING AGENCY
1 hereby affi�m that there+s o ronst�uction!ending ogency for.
ithe performance of fha work for which�his permit is issued pERM1T FEE (Sub-Total)
I (Sec.3097,Civ.C.}.
PLAN CHECKING FEE
� lendei s Nvme
PERMIT ISSUING FEE
Lendei s Address 73��
I certify tha�1 have read this app�itarion and sta�e�hat�he TOTAL FEE
a6ova informoiion is corcetl.t ogree ro comply wirh all Caunty
ordinances and SMte lows ragulating EleUrico)wiring,and
hereby authorize represemmives of�his County to enter upon
�ihe above eniio�ed openy for inspact�on purposes. SfE REVfRSE EOR fxPLANATORY LANGUAGE
�� !��/ 8/20/86
Signature of Permittee Daie
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