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HomeMy WebLinkAbout0831A WORKERS'COb1PENSATIONDECLARATION � 76n663 APPLICATION FOR �ELECTRICAL PERMIT � � y� � CE-806G(2�80) I` , 1 hereby attirm that 1 ha.e d certiticate ot consent to self COUNTY OF lOS ANGELES BUILDING AND SAFETY U insure,or a certiflcete of Workers'Compensation Insurance,or� � � � a certified copy fhereof(See.3800,Lati.C.) � Wp81-b2494 Freemotn Indemnity FORAPPLICANTTOFILI.IN• J09B�(�O - II�t �jG - D $� n Center Policy No. Company EACH NO. FEE , ADDHESS� 9 3� 8Z� New Residential Bldgs.&Poois - ❑ CertiGed coDY is hereby furnished. � � 1&2Family,Sq.Ft, $ — a LOCALITY TR#41305 - Di amond Bar �.Certifed co ' Multi•family Sq.Ft. � — A py is filed with ihe county building inspection , Residential Swimming Pools CROSS S7 departrPent.� � � OIWFiMNA E Presley Co. � Date 11 ZO 81Applicant C MC�,P2 E�2CtP1 C Outlets:Ree.�Light 6 sw.� -_ ,60 . 9 5. 0 AooAEss. 4600�Campus D1'. � - F��n zo CERTIFiCATE OF EXGMPTION FROM WORKERS' Total No. 9 - Additional c�Tv Newport Bch, Ca T.�No.540-0500. - } � � - ..COMPENSATtON WSURANCE- � . � a � � - � � , � , . PLAN CHECK � (This section need not be completed if the work u1vOlvCd AVPLICANT V _ Lighting Fixtures First 20 �� - by the petmit ls for one hund[ed doilara(f100)or less.) ADOFEss � � Total No. .� Additional � I certity that In ihe pertormance ot the work for which this Fixed Appliances Not Over 1 HP � CITY Tel No. U permit is issued,I shall not empioy any person In any manner PERMIT . W ' so as to become subject fo the Workefs'Compenaatton Laws. Range_Heater D.W._ APPLICaNT �. . . . � . . . . �OVan _Dryef-_W.M._ . . - ADDRESS . Z Date Applicant � Top _FAU _W.H._ . . d7Y Tei No.� � Hood_Fan _Other_ -- - NOTICE TO APPLICANT:If,after making thts Ceitiflcate oP Disp. _Room Air Cond._ LICENSE oR C-lo . ExempNon, you should become suAject to�the Workers' REG.NUMBEq 153378 Class . Compensation provisioni of fhe Labor Code,you must forth• Power Apparetus&Large Appliances � DISTflICT NO. . PROCESSED BY with comply with such provisions or this permit shall be Size&Type HP,KW,KVA,or KVAR ' �deemed revoked. . � . ' �Q . �Ct.u-«� � .. ' Upto t lncl. . . . . . FINAL� ' � Over 1 to t0lnci, oATE '/ VALIDAT�ON � LICENSED CONTRACTORS DECLARATiON ' Over 10 to 50 Incl. Y a 1 here6y affirm that I am licensed under provisions of Chapter . . Over 50 to 100 Inc. FINAL � . - � BY 9 (commencing with Section 7000)of Division 3 of the 8usi- Over 100 ness and Rotessions.Code,and my Iicense is in full force and � � . � � effect. Services . - - � •153378 C-IO 0-200 Amp.Under 600 V Lic n¢ Number� Lic.CJass � � � � � �Lf� MC ee E�i c, 111C. • 2014000 Amp.Under 600 V � � � ec r Cnntractor_�� Date 11%91l/Rl� Over 1000 Amp.or Over600 V � . � . � HOME OwNER•BUILDER DL•CLARA7[ON� - � Temp.Power Pote&Appurtenances . .� � �. . 1 heretiy affirm ihat I am ezempt trom ihe ContractoPs Sign with One Branth Circuit - � " � � . �� ' - - � License Law�for the foltowing reason(Section 7031.5,Husi- Additional Sign Brench Cireuits . , : ness and Professions Code): . � -?Q�2 j,� F� Mise.Conduits&Condactars - � 1,as owntr of the property.will do the work and the Other(See Complete Fee Scbedulel� �,!e . •2 - . structure is not intended or offered for sale (Section - - . 7oa4,Susines�and Protesaions Code). � . , CONSTRUCTION LGNDING AOL•NCY . ��O ° � 3..�i O� . I hereby atfirm that there is a construction Iending agency ' � � " - -� � - � _ � for the performance of the work for which this permit is pERMIT FEE (Sub•Totall 5, Q . e `? µC�U � issued(Sec.3097,Civ.CJ. _ � � -. � . � LendePs Name � �PLAN CHECKING FEE fOne•Fourth Permit Fee) � - � �•�v_�`•� . Lender's Address PERMIT ISSUING FEE � � � � 1 certify that I have read this appiication and stete thet the TOTAL FEE � 13. � above intormation is corfect.T agree to comply wiih ail County � ordinances and State lawre regulating Electrical widng, and - - hereby authoriae represenlatives of this County to enter upon � . - ' ' � . ' . � the a6ove-mentloned property for tnspecNon purposes. SEF.'REVERSE FOR EXPLANATORY LANGUAGE . � �ig_natur�mittee � D� . . . . . .� . . � . . _. . . 1. 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