HomeMy WebLinkAbout0835A (4) V/O4KER5'COM.PENSATION DECLARATION �yA�� ��,81 qpp��CATION FOR ELECTRICAL PERMIT
I hereby oflirm ihai I hnve n cerr�ficn�e ef consent to self �E"� �
��su�c,o.n cc�rfmie of wo�keri Compe�snuon�nsurante, COUNTV OF LOS ANGELES �2 BUILDING AND SAFETY
or o cer:ifind co�y therr,of�S�c.3800,lob.C.)
P❑ol�icyNo.�I61JB1Qx,y,�Pe��IRM INS BROKERS FORAVPLICANT70i1LLIN .108 �}� .
Cerlified copy is hernby furnished. EACH NO. FEE AC�RE55��pL.�
New Rasideniial 61dgs.8 Pools ia�AiiT� DIAMOND BAR
�}tCPrlifled cepy is flle.d with ihe county building Inspec- �8 2-Fnmily,Sq.Fi.��� E — 5
lion deparlm nt. Mulli-(omily Sq.FI. �,S�S — hF�NEST
Residenliol Swimmin Pools caoss sT. DIAMOND BAR & GRAND AV
Da�e ��pplicon�WATMAN F.T.F.C`TRT(,` /�� 9 OWNERO4
GERTIFICAT OF EXEMPTION FROM WORKERS' "'�"��� � � hAM NAME PRESLEY OF SO CALIF
oode kec �igh� Sw. CAMPUS DRIVE
COMPENSATION INSURANCE First 20 ADDRESS
(Thls��c�ien naad nol bs eompla��d Ii tho work inrelv�d by To!al No.� Addiiio�al CITY Tel.N
tha parmif is for ona hundred dollan(f100)or lass.) —
I certify thr.t�n the per(ormance of ihe work for which ihis PIAN CHECK
APPLICA�:T
perm�l is issued,I shall nof employ any persan in ony monner .
so as�o becor�e subject to�he Workeri Compcns�tion Laws. . liqh�inq Fiz�ures� Firsl 20 � ADORESS
To�ol No. Addilionol
Dare Applicant ��TY Tel.No.
NOT�CE TO APPL!CANT: If, ofter rnoking ihis Cer�ificoie o( Fixed Appliances Nol Ovor 1 HP PERMIT WATh"AN ELECTRIC IN�.' '
E.emptien, you sheuld F.ecome s�bieci to the Workers' Range_Heaier_D.W._ /���Cnvi
Compensa��on p.ovisicns o1 rhe Lobar Code,you m�sr fo��h• O�en _Dryer _W.M._ ADDRE55 20921 AVENIDA AHIAPOLA
I with comply wi:h such provisicns or this perm��shoil be Top _FAU —W.H.— _
deemed re�o4ed. CITY Tel.N
LICENSED CONTRACTORS DECIARATION Hood _Fon _Other_
I hereb oflirm�har I om licensed under P Disp. _Room Air Cnnd. — liLfKR OR
y p�ovis�onsofCho �e�9 FFG.NUMBER43317�} C�osL.`—].�
(cemmencina wiih$ection 7000)of Oivision 3 of ihe Bus�ness power Apparofus 8 Large Applionces �ISTRICT NO. PROCESSE�BY
and Professions Code,ond my license is in full iorce and eHect. �
Sire 8 Type HP,KW,KVA,or KVAR 1 �'
License Number 433174 u�.ei�-10 �p�o� ���� F�•VA� / �
co��.aaoZ'VATMAN ELECTR7�. o�a�i�o 101nd. DATE 3 �7 �t� m
e YAIIDATION �
❑ Over 1010 50 Incl. FINAL V
I am exempi�nder Sec. p„A�5p�a�pp���, gy����� a
B.BP.C.for rhls reoson �"P��� v/
Servicr.s,Swbd.,MCC 8 Panel6oards ► Z
Dn�r..: 0-700 Amp.Under 600 V
Sfgna�urc �01-1000 Amp.Under 600 V :�C�a S��
❑ E$c� O�er Ip00 Amp.or Over 600 V
p'�on for Re.g.!.laint.Elc:l. ��• • • • •2
S!NGLE F,4.M!lY Temp.Power Polr 8 A�purtenantes
Fi0!�AE OV�tiER-BUILCER DECIARATION S�gn wiih One 8ranch Circuil ' � • •6�7�.
I h�rcby o7firm�Fc�I nm e.empl from th�Conv�Ner's licecse
Levv for the follo�.ving reason(Sec��on 7031.5,B�s�ness and Ad�1�r��nol S�gn P,.an�h Ci�c�irs �'� ���.�;�
Prnfesslons Code):
� Misc.Conduiis R Conduc�o.s Q� � �—�[4
I,os own�r o1 the proper�y,will do Ihe wark ond ihe �
srrucrure is not inrended or offe�ed for svle(Seciion Oiher(See.Complete Fee Schedule�— ► '
70eq,8usinFss and Profess�ons Cede�.
CONSTRUCTION LEhDiNG AGENCY
I here6y affirm thnt Iher�is n conslruclion IC�ding ogenty far
Ihc performance of ihr.work(or which ihis permit is issued PERMIT FFE (Sub-Toial)
(Sec.3097,Civ.C.).
PLAN CHECKING F[E
� Lender's Nome
PER,MIT ISSUING FEE �
Lender's Address
I certlly rhm I hwr,rcad ihis oppl;�anon ond s�a�r.thar�he TOTA�FEE
obove�niorma�ion rs torrecL I agree to comply wiih oll County
ordinancrs ond S� �e lows regulaiing Electrical wiring,and .
hereby auif rir represenia!rves af this Couniy to en�er upon
the v - iiened propen lor' spr.ction purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
�,,, , /3 d'
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