HomeMy WebLinkAbout0839A (4) L"lO4KER5'COMPENSATIONDECLARATION ���� ���81 APPLICATION FOR ELECTRICAL PERMIT
I horeby eflirm ihot I hove a cer�ificnte of cansenr io seii �E"� �
insurr.,o�o ceri�l�cair.o(Workers'Compensation Insurance, COUNTY OF LOS ANGELES /��3 BUILDING AND SAFETY
o�.a certified copy therrof(Sec.37W,Lab.C.)
O�YNo F)Z�TBZOI�OomPa�YIRM INS BROKE FONAPPLICAMTOFILLM JOB
Cerl�(irtd copy is hereby furnisHed. New Residenliol Bidgs.8 Pools EACH nk7. FEE /DDRE55 �
}}�{(Cane(ied copy is filed wieh ihe coun�y building inspec- I 8 2-Family,Sq.ft. S — E LOCALITY DIAMOND BAR
iiol deperim.,en Mulli�(omily Sq.FI./7P� — S NEARESi DIAMOND BAR & GRAND AVE
Residen��alSwimmin Pools Ca0.555i.
oa�e nPPi;�o�iWATMAN ELECTRIC 9 OWNEROR
A�(' FIRM I.AME PRESLEY OF SO CALIF
CERTIFICA E OF E%EMPTION FROM WORKERS' Ou�lets:Rec�Lighf�5w.� '�'A��
COMPENSATION INSURANCE r Firsf 20 3 ADDpE55 CAMPUS DRI VE
(Th(s a�ctien nv�d nof be complel�d if Ih�work Inrolrod by Total No. ��7 Additionol CITY NEWPORT BEACHTP��N��540-0500
tha permit is for ono hundrad dollon(3100)or la�s.) P�qN CHECK
I ter�ify th�t in ihe perlormance of�he wo�k for which Ihiz APPIICANT
pprmit is issuPd,I sho�l no�er�ploy ony person in any manner
so os io bnceme subjeci io ihe Workers'Compansolion Laws. Li9hting Firlures F�rs1 20 ADDRE55
To�al No.� Addilional
Date Applican� ��TY Tel.No.
NOTICE TO APP(ICANT: If, of�er moking ihis Cerri(icole o{ Fixed Applionces Nol Over 1 HP ff4M�� WATMAN ELECTR2C
Eaemption, you should he.come subject io ihe Workers' Ronge_Heo�er_D.W.— AmLiCANT
Compensn�ion provisions af Ihe Lnbor Code,ye�must(orth- Oven _�rynr _W.M._ ADDRE55 20921 AVENIDA A�iAPOLA
with comply with such provisiors or ihis permit sholl be Top _FAU —W.H.—
deemed revoked. Hood _Fon _O�her_ CITY Tel.No. _
LICENSFD CONTRACTORS DECLARATION
I he�r.b offirm�hot I om licensed under P Disp. —Room Air Cond. _ LKEI:SE OR A
y provisiansofCho ter9 RFG.NUMBER'�33�-74 Closs. C-10
(commencing wirh Secrion 7000)of Division 3 of�hn Busiress power Ao ra'us 8 Lar e A liantes DISTRICT NO. PROCESSED BY
end Profess�ons Code,ond my license is in iull Force and effecL PO 9 PP �
433174 C-10 Sire 8 Type HP,KW,KVA,or KVAR Q 0
Li<ense N�mber lic.Closs �p�o����� F�Nq� V
co�„��,WATMAN ELECTRI�,� Ovxr 1 to 101nc1. DATE � �J p�� yALIDATION �
❑ Over 10 to SO Ind. �. �� ►-
I am ex=m ��r.dcr Sec. FINAL
P Over 50 fo 100 Inc. BY �.r�/.��- W
8.8P.C.for!hls recson �°^��� n'� " N
Se.rvicr.s,Swbd.,MCC 8 Panelboards . U 2
Dnr�: 0-700 Amp.Under 600 V
Signa�ure ?Ol-1000 Amp.Under 600 V
� O�r.��000 qR+v,o�Over 600 V -=O E3 3 9 A
E.em,fian(cr Reg.ldaint.Eleci.
S!NGLE FA.14!�Y Tem Powr,r Polr R A *`� � � � 'L �
HOME OWNER�BUIIDER DECIARATION P' �punenonces
I hereby affirm thcl I nm eremp�freri�h=Cen!�ecror's Licensr. Sign wiih One Bronch Circuil � • •�]Q j(,
Law for ihr.iollowing reoson(SeU�on i031.5, Business and Add'�'°^^I S�rJn Br�n�h Circ�i�s
Professions Code): . •� o j r j(��
❑ I,as owner oF Ihn ro Prt,will do ihe work ond the M;sc.Conduits 8 Conduc�ors
strudvre is nat inirnded or oifered tcr sclF(SeUion Other(See Compleie Fee Schedule)— O L O�"O�i
704�,9usiness and P�alr.ssions Code). ►
CONSTRUCTION IEND:NG AGENCY
1 heroby affirm�hat�her�is a cens�ruction Iending aqency for
th�pe�(ormoncr,of ihP werk for which rhis permit is issued pERMIT FEE (Sub-Tarnl)
�Sec.3097.Civ.C.�.
FLAN CHECKING FEE
Lendcr's Namc
PERMIT ISSU�NG FEE �Q
Lender's Address
I ce��ify iho�I hove rend�his opplica�ion and s�a�e thot�he TOTAL FEE �
above in(ormaiion is correct.I agree�o comply wi�h oll County
o�dinoncrs nnd ir. laws rr.gulniin9 Eleclricnl wiring,nnci
hereby au+ o�� represeNatives oi�his Coun�y 10 eNer upon
the ,i�oned proprt.iy for ins,^.ec�ion purpcses. �
SEE REVERSE FOR EXPLANATORY IANGUAGE
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