HomeMy WebLinkAbout1654A � - YNORKERS'COMPENSATION DECLARATIQN 76A663 IO/81 APPLICATfOM- Ff)R ELECTRICA! PERMIT - � '
�� I hereby dffirm thai t haye a certificqte pf consent to self �E-�� . . .
insure,or m certificate of Wwkers'Compensaxion 4nsuronce, COUNTY OF LOS ANGELES BUILDlNiG AND SAFETY
� or u certifi.ed copy thereof�Sec.3800,tab.C:)� . -
___
PQoHcy No.�C'7777dE3S[i'ompprry ,� . .. .._ .. __ .. _. . FOR APPIKANt TO HlE tW - JOB . . . . �..
dl#ied t4py i5 hEfEhy.fLIRtSFted.� . .__.._.. P}ew Residantiql 61dg��1�"�' EACH NO. FEE A�DRES$ • .
1&2-Famil LOCALtTY
. • . Certi fied copy is filed with the county building inspec- Y��9�F. _ 5 — ; TR 35581 Diamond Bar 4
�- �NEAREST
. fion•department. � - � Mulfi-fomily Sq.F. CROS4ST. --
•3-2?-A�+ - µT° NCX•F,F, FY�f,RT. Residential Swimming Pool: OwN€R O�t �
__ Date - - Applicant�, �C .. . PIRM.NAME .�T�IEL7. TI1C .
. CE RTIFtUTf OF EXEMPTION-FROM WORKERS'� Outteh:Rec-4ight_Sw.� � � ���°'�t -
- COMOENSATfON tNSURANGE . �AODR • �
First 20
- (This�eetion naad nM br complN�d-it tha wark involr�d by Total No. 9,ddirionat ��T� •� TeI.N
. fhe permi#is 1ar orro h�nd�s�dnitarr�{'j#iWjor tesa:} � - - �
- - PtAnt CriEIX _
.. 1 certify.thia in�fhe perfwmc,nce of the work Eor which this - qpp��qM
�permit is iszued 1 shqll no1 employ any_per;on in ony monner -
so as to b�come subject to the Workers'Compensation Caws. Lighting Fixtures first 20 qppgEs$
� . Total No. Additional . -- .
. Dafe o.gPfimnt G7Y Tel.No.
NOTICE Td APPLICANTi tf,�affer making this Certifimte of - F�xed App�iances Not pver 1 HV . pERM�T �� ��
ExempEian„ you should�.6ecome. subject to 1he_Workers' Range_,Neater_D.W._ � ��«NT
Compensanion provisiom of the to6or Gode;'ya�r-must farrh- Oven �Dryer _W.M.— R6DRESS 1
wfth-comply wi�h such..provisions a�thes permit_shgll_be -- --I FALL_._.1M'H__. .
°�--
dee�ed r�voked.. .. . : .. . . .. ... __ . G7Y - -. � TeL No.
�- L�CENSED CONiRAC70RS DECLARA110N Hood _Fan _Other_ -
Di _Roam Air Cond- — tiCENSE OR
1 hereby af#irm that I am ficensed under provisians of Chapter 4 �' - REG.NUMBER C��� -
�- (commenci ng with Section 7006)of Division 3.of the 8us'rrress _ power Appowtus-&Lorge Appliances D�STRICE NO. PROCESSED BY � �
� ar�d Pr4f�s��QnsS�lB Sz�.m�.f s�n�g��n f�1f srsg�n��ffec�,. _. .. . .. a
_ .._._ . .._ -..__._._._.__ ...-- - ---- .- --Size-8-7YPe-HF>K�J,KVR,-c+r-K1FAR'- ---- -_ __._ . ..____ ---___.. _. �-_- ...
. , . t __... __-_ .:___ . _�. .
- Licenu Nu+mt�er�_�7GR -�;G-C� d'--7[1 Up to 1 Incl - � FINAI - u
� _. _. ..,.-. ..___ DATE
�'- - - � --- - - -�-� Over 1 fo 10 Incl. �
Contractor F�-Zcx'tY��'a�l Dn�e 7 2�-$5 � - E�-12-��� YAL{DATION Q.
O . . Over 70 to SQ Incl. F�
�-am eKempt ur�Sec. .-. . -. ... .. .Over 50 to 700 inc BY A� uVi
8.8P'.C.for fhis reason� - - � Over 100 �
-� . Servlces,Swbd.,MCC 8 Panelboards - � . �
-_ .. _. Qate: _. .-_.tI-.=2W-.4mp:Under Bq�V_ . . . ^
... . Sign.e�Fure � .. �-261�-1000 Amp.Under 600 V .
.�
❑ - � OYer 1000 Amp.or pver 600 Y � $� b 5'U'A
Exemption io�Reg.Maint.Efed. --
�� � • ��2
- � SINGLE FAMICY . Temp:-Power-Fc3Ie�&�Appurfenartces . �
HQhAE OWNER-BUftDER DECIARATION $�yn.wiih-Dne.Bsanch Cucuit. -�.• � �'1�J��
� 1 hereby affirm that Lam exemastfrom�the Coniroctor's ticense Additio�al Sign&anch Cirtuits � -- � � �� � x
__ Lawe for th�e fallowing reason(Section 703L5,Business ond � _ - _ � �,�„Q�,
Pro€essians Code}: � -
� 1,as Qwner of the properry,will do Poe work and ihe Misa Enndul�s 6 Conductors - F���J�-S S �
' strurtura is no�intended or offered for sale(Section a�6er(See Complete Fee Schedule)_ - � � � -
.' 7D44.;&usinessandProfessio�s-Code).... -. . . . .
- . CONSTRUCTION LENDWG AGENCY . - � � - � -
F I hereby oFfirm fFrot there es a constvuction lending ogency for _
. the pertorrnance of ihe work 4w which��this permit is issued � pERMiT fEE---- . -.- . - _.- - ---.(Sv�Fotvt ---.-. .---.. .. . .
- (Sec 3D97,.Civ.L.).-.__ _ . _ ._ . . � . . . . .
. . . � --�PLAN CHKKING FEE - . _ . - .
lender's N ome . -
' . PERMIT IS5UlWG ff€... . . 0
� lertder's A�ddrass � �- � - �
- I certify th�at t have read this appiication and state�hat the TOTAC FEE � �� �
� above informafion is mrrect.l agree ro comp�y with afl County . . -
- ordinonces and Stote lows�egulatiag Electrical wiring,and ._ � �
. . here6y authorize representarives o#ihis Covniy to emer upon _ _ _ . � -
ihe ove-mentiorrcd propertyfar-impec�rortporposesr� � �
SEE REVERSE fOR EXPLANATORY LANGUAGE
�`�,�7� -�6 I
�Signoture�oi Rerminee� � ote � � � �
F h � u T u O�O �� ' ,
. h C .:.� G�y ' p� � � � � . � .
. �'C V1 N Q fl.ti -4j � �H � CL
. � u`iy`� � �+ 3� �� �7-c .a[ 8 i pd� � � .
- . V `d�`.�..`-DO�,r� � 0. �.� p = p Va�� � �}^ . ' .
:g� �m"° " � � � 3m� ° �m� `�
n u � o �cv � � i m e�" m..°c � o> „°,
. o ` �� mrnrmoocu»- t � c3g �oao
lJ � u > c N O � i^ E�.[] 8 'O.� m ;'O 6 . -
. ' Q.- L Vf O �n� p'u N O O h 'd V O b � 3 �W C O .. � � � � .
� M V+ 4)�"r , `/ y f m � N O ^' � }�41 Q.
q Ec �� � o�ama� Eo � o o�sm� �
" u! °� o y.`._ .. omnscmE � a Na'm N= o.'a �,
a m4:'. oE�at aQao 00�6� mcm� � c
W E .. o � m �.°c o � � ° � a'a ° �o.z� d N
m N N N
w w3v � a� Q3cm °'c� '= m � m �v`��° a� � �
0
O E° N c ai �'o °„ m m $o �� N o a>d °�` o . � 't
oo � o � oM �.ax c �vEa � 3fl- '
� _"' ° � '" c m a,a � m d m � `� °' ,, E �,
m o h °? c � c� t-a a°'.. i N».� o� o c-o •. E `�
.,_
�ii �"� ° EN� h,–,���.o °��>$ ,nm'ah� N ° F °a x V c
Z o a • �.ti.` � ° a �,� � � C E�n ��'� w a �'
3 � � c„oas�o�u �.o�+..: v� u�=� � d,n � ,ty o Q
� � � O O.ti �r.pfi �*i� � m vf � i Q N~ �n O� V���-C 4 � fA � .
S 4' Q' � O�' .�o-. O p N'.._-.r, V �'�..G 0 y � p G .�
c"" � c �a�o s� o � } '
u � c� ° �� o m o 00 �-o
su � m� DEv'^ �»_
, , J
m � p °�
. �
F' {\f
Z J
I9 1 M
N � f
r'
re.
L
a `�� �
o � °
�` `
�
�
W
� �
u
w y p
4 � � a � p �
a � m � (� � O
V� N
d S t'J oc � � 4 ��"" �
¢ � � � 'Z � � = Z O
a, p � � � � .�. Z .
� � � 3 LL
, ��.�---� ~�
—._`--•-"_
__------_"
-_-----'�`"`.�---�-'_��