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HomeMy WebLinkAbout1654A (9) � - 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 � � � � a ��o°-�° c . v c ' °��N � os , y �No�y � �,� a°�m� d . �l �U N��~_ ���,��tl � O m p� � dp �G p � . , . y O 6 6 +L �l 9'G �. 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