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HomeMy WebLinkAbout0828A (4) � WORKERS'COMPENSAT[ONDECLARATION - 76A663 APPLICATION FOR ELECTRICAL� PERMIT � � . {� � � - CE806G(2-80) . I hereby affirm.that I have e certircate of consent to se�f � C�UNTY OF LOS ANGELES BUILDING AND SAFETY l, insure,or a certificate of Workers'Compensation[nsurance,or . . �D� q6 ' a certified copy ihereoP(Sec.3800,Lab.C.) � �� ��H�-F)Z4g4 � FY�EeI11OTIt I(ICI2III�1�tJ� . FORAPPLICANTTOFILLIN ' JOB B� 9 1 - U ltS 74�7 � � Polic o.� Company EACH NO. � FEE ADDRESS 23 d 0 � � ` New Residential Bldgs.&Pools � � Certified copy is here6y furnished. 9�3O�HZ � � �g�Q.Family,Sq.Ft.� $ — $ �ocAUTv TR#41305�- Di amond Bar � CerNfled co ' y g P Multi-family Sq.Ft. '�`R py is filed with the count buildin ins ecfion CRO55 ST �-department. . Residential Swimming Pools . owNett oR . ' IAppliCenC �•I PP F ert lC FIRMNAME Presle .Co. � . uate 11� 1 P Outlets:ftec.5 Li9ht 5 Sw.9 MA�L 4600. Cam US Dr. . F;,St2p •60 19 11. 0 nooRess p CGRT(rICATE Of•EXEMPT[ON FROM WORKERS' � Total No.19 Additional ��T�New ort Bch. CTt�"°.714-540-050 } � , . COMPENSATION INSURANCE , PLAN CHECK � � 4 ' � APPLICANT � - - (This section need not be completed if the work invoWed Lighting Fixtures First 20 ADDPESS U 6y the permit is for,one hundted dollars (5100)or less.) Additional � t certiry thet in the pezformanee of the work for which this Total No. � � CITV . 7a1 No. . ' -� � ermit is issued,I ahall not em Io an Fixed Appliances Not Over 1 HP . p p y y person in any manner � � PERMIT . W so as to become subject�to the Workers'Compensation Laws. Range_Heater_�.W._ � APP ICANT � y � ' � . � Oven _Dryer�1N.M.� � ADDRESS� �G � � � Z Date - ApD�icant - �� � Top _FAU �W.H. � , — � � Hood_Fan _Other�-C7. . Open 1' CITY Tsl No. NOTICE TO APPLICANT:�14 efter making this Certifcate of Disp. _Room Air Cond._ LICENSE O C-lo ' Exemption, you should bernme subject to the Workers' � - REG.NUMBER 153378 �c��.: . - Compensation Drovisions bf the Labbr Code,you must forth• Power Apparetus&Lerge Appliances OISTRICT NO. PROCESS.�D BY - with comply�with such proviSions or this permit shal� be Size&Type HP,KW,KVA,or KVA � � deemed revoked. � � � �0 - . Up to 1 Inel.-� � � �� - �-� FINAL � - Over 1 t0 10 Incl. DATE / "� . LiCENSED CONTRACTORS DECLARAT[ON Over 10 to 50 Intl.� - �7 �-/� �aZ VALIDATION � I hereby alCrm that I am Ilcensed under provlsions of Chapter Over 50 to 700 Ina FInIAL � . BY 9 (cammencing with Sectlon,7000)of Divlslon 3 of�he Busi- p,re��pp nese and Rofessions.Code,and my license is in fuil force and � ' effect.. � Services � � � � License Number 53378 � ue.c ass C—lO � 0-200 Amp.under 600 v ' . �- ' O11C��. e�1C� �fIC. - ��•��Amp,Under600V� Contractor��f _ .i r-a�f •Date_ 11IZOIHl� � Over 1000 AmP.or Over600 V � . � � HOME OR'NER-BU[LDLR D£CLARATION � Temp.Power Pole&Appurtenances , . � I herehy atfirm that I am exempt from the Contrector's Sign with One Branch Circuit � � � , � � . � License Law for the tollowing reason (Section 703t.5,Busi- Additional Sign Brench Circuits . `0 8 2 8�. ness and Professions Code): . . - � �. � l,as owner of the property,will do the work and the ' Mise.Conduits&Conductars e' � . s[mcture is not intended or offered (or saie ($ection Other ISee Complete Fee Schedulel— �� �.� �� 7044,Business and Profeuions Code). � • � 4 3�7 J � - � CONSTRUCTION LF.ND[NG AQENCY [ hereby affirm that there is a consttuction Iending agency , � �•� �l:%�c=,� � . for the performance of the work for which this permit is pERMIT FEE (Sub•Total) , issued(Sec.3097,Civ.C.). - � � � � �,2�J.a.��� Lender's Name PLAN CHECKING FEE (One•Fourth Permit Fee) . � � � . - ! LendePs Address� pERMIT ISSUING FEE . � � , 8. � . , 1 certity ihat 1 have read this apD�icalion and state ihat Ihe TOTAL FEE � .143. 5 � . a6ove infotmation is correct I agree to mmply with aIl County . � � _ " ordinanres and State laws regulating Electdcal wiring, and . � � � hereby authorize rtpraentatives of ihis County to enter upon � , . . the above•mentioned property for Inspection purposes. SEE'REVERSE FOR EXPLANATORY LANCUAGE � � � � TQ�+'�it� 11/�&1 C.iaigna[u f Permittee Dete . . . . . � ;.I+", ••JN � .•�• . . . • ..r ^-, � +�l ' _� �.. � �, , `�`. . � � ,;`.. s 1 .�t' 11` �``t''. �� � �1, ,..-1 `�. . . 16. .. ,�, ', 1`. 11 ' �, il t i, ' . " , . 1,�.. � . . 'f�'1: "� �..' _ �t, � .` �f• � �'�,,�� �� : + 1_ . 1 ' �. � � �c��� , , �, ��� �. �,• . - � � : ''^ � � -..1- �' '' , , � ,-n �'. 0 �. ,�.a. G � � 'b .. • .. � -� O y C ��T'. C ����' �' � p . . .. • , . ;N r n. D N, , � a 9 �Y , � ' l, , " O ��. • O o o N � . 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