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HomeMy WebLinkAbout0830A �WORKERS'COMPENSATIONDECLARATION � 76A663 APPLICATION FOR ELECTRICAL PERMIT � � � ` CE�806G(2�80) i heieby atfirm that 1 have a certiticate o[consent to seit COUNTY OF LOS ANGELES BUIIDING AND S{1PETY insure,or a certificate nl Workers'Campensation Insurance,or - , , a certifled copy.thereof(Sec.3800,Lab.CJ 7 ' WP83-62494 FT�eemOl�t irldelrlClt�,�/ FOHAPPLICANTTOFILLIN ��6 Bldg - n't 78 - S les ffice Policy No. Company EACH NO. FEE �+DDRESS � � New Residential Bldgs.&Poots � Certified copy is hereby furnished. - 1&2•Family,Sq.Ft. ' $ � $ LOCAUTY TR#41305 = D�amond Bar �� � Certified copy is tiled with the county building inspectian Multi•family Sq.Ft. CRO55 ST department.� Residential Swimming Pools - OWNEn OA . � li. � 81�. � FIRM NAME Presley Co. Date Applicent r �''�GC22� E�2GtP1C Outlets:Rec.4 Light20- �Sw. 9 ,6O ZO � ZZ. O� AD�RESS 4600 Campus�.Dr. � First 20 CERTIPICATE OP EXEMPTION FROM WORKERS' � Total No.� Additional c�TY New ort Bch. Ca r•�No.540-0500 } . . COMPENSATION INSURANCE , � . � � . PLnnl CHeCK - - n' APPLICANT � � - (This section need not be campleted if the.work invotved V - by the permit is for one hundrcd dotlazs (5100)or IesSJ Lighting Fixtures First 20 ADORESS p� � � Total No. - . Additional - � I certify thet in the pettormance of the work for which this CITY " Te�No. ' F- permit is issued,I shall not employ any ptrson in any manner Fixed Appliances Not Over 1 HP pERM1T � W so as to become subject to the Workers'Compensallon Laws. Range_Heater D.W._ � APP ICANT •N � ' . . �Oven _Dryer_W,M._ pooRESS � - 2 Date - Applicent � � � Top _FAU W.H., � . . . . . - - - - Hood—Fan �Other_ CITY �Tei No _ NOTICE TO APPLICANT:[f,a[ter making this Certificate of Disp. _Room Air Cond` . 3.� 1 � 3. O. ��CENSE OR �C-lO " Exemp[ion, you shouid become subject to the Workers' REG.NUMBER 153378 � c�..� Compensation provisions of the Labor Code,you must forth- power Apparetus&Lerge Appliances DISTRIC7 hlo. PiiOCES;ED BY with compty with such provisions or this permit shall be Size&Type HP,KW,KVA,or KVA - % deemed revoked. - �d ��G[-�1�� � � Up to 1 Incl. . . . ,.. _ i, . . .. . .. PINAL � . O�erltot01nt1. DATE /� 8'2 VALIDATION LiCENSED CONTRACTORS DECLARATION� � OVer 10 to 50 Incl. � I hereby.affirm that 1 am licensed under provisions of Chapter OVer 50 to 1001nC. FINAL - � : � , 9(commencing with Sectlon 7000)of Divislon 3 of the Busi• Over 100 BY ness and Professions.Cdde,and my license is in full force and - effect. � . Services � ' �� � � License Number 153378 Lic.€lass C-10 0•200 Amp.Under 600 V . ��C�� McGeP�QC�Gs +nC• ��•��Amp.Under600V . . � . � . . Contractor I Date �11�2O�H1 � Over 1000 Amp,or Over 600 V . , � - - - HOME OWNER-BUiLDER DECLARATION � Temp.Power Poie&Appurtenantes . . � - I hereFy afflrm that t am exempt trom the-ContractoPs Sign with One Branth Cirtuit � License Law for the tollowing reason(SecNon 7031.5,Busi• Additional Sign Brench Circuits � � ness and Professions Code): . , � � " ' � . � � � Misa Conduits&Conductors � � - . � I,as owner of tfie property,wil�do the work and the Other(See Complete Fee Schedule)— , � � stmcture is nnt Intended or offered for sale (Section - . _ .. ' 7044,Business and Protessions Code). . � � � � � CONSTRUCTION LtiNDING ACENCY � -�'O 8�•C A � [ here6y affrm ihat there is a consiruction lending agency� � � � " � � � � � ' for the performance of the work for which this permit.is .�� _ •2 issued(Sec.3097,Civ.C.). � PERMIT FEE (Sub-Total) . 'L0. 0 . . . � �. . . . Lender's Name PLAN CHECKING FEE (Oae-Fourth Permit Fee) �''�'2 a 7� , • . LendePs Address PERMIT ISSUING FEE _ $. O �.' '����O c�'.+ , 1 certify that I have read this apD���a�ion and state ihat the TOTAL FEE . 'L8,]Q � � �.2 J�,-�� . �ebove information is correct.1 agree to compty with ail Co�mty . . . ordlnances and State lav.s regulating Electricai wiring, snd - � . . _ � , � � � , - hereby authorize representatives of this County to enter upon � _ _ _ . � _ _ the ahove•mentioned property for inspection purpnses. . SEE'RLVERSG P'OR EXPLANATORY LANGUAGE ' ' �. - 5�"� l i 120181 ' • Signatur Permittee Date� . � �� � �.� ' ' . - -' . i. �,,,I:. . .i.��-f .�.. +._..� ... .., ..= �e .. , . .� . . I , _ � t i I � , . 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