HomeMy WebLinkAbout0840A WORKER$'COMPENSATION DECLARATICN 76A563 IOi91 '
I hereby atfirm ihoi I ho�e n cr.rfifirnlc a,�o�sP�<<0 5��f �F�� APPLICATION FOR ELECTRICAL PERMIT �
insvre,or o cerlilic�ln o(Wor4rrs'Compensai�on Insurance, COUNTY OF LOS ANGELES �1`,3 BUILDING AND SAFETY
m rnceruRed cepy thernof(Sec.9A70,La6.C.)
O�Yye,�JGIJB1O��p��YIRM INS BROKERS FORAMIICANTTOFIILIN �UB �y� ,(
Ceriified cepy is hereby Iurnished. New Residential Bldgs.8 Pools EACH iv0. FFE
ADDRE55 �O�J r �� �
� Ce�iified copy is file.d with thn county build�ng inspec• 1 8 2-Fomily,Sq.Fi. S — 5 LOCALITY DIAMOND BAR
tion depo��me � Mulii�family Sq.FL 70/ — � ` �lEARFSi
ceoss sr. DIAMOND BAR & GRAND AVE
Resi�lenlial Swimming Pools
Daie � � AnplicaWPiMBt'J FT.R('TRTC` U'NNER04
CI�y��;{�N.� —'J FIRM NAME PRE
CERTIFIC OF EXEMPTION FROM WORKERS' Ou�lets"RecL�'�Li hi�5w� MA��
COMPENSATIONINSURANCE �9 First20 ��DCE55 4600 CAMPUS DRIVE
�This�aclion nead nol b�eo�npl�l�d I(1h�work inrolrad by To�ol No._LZ Addi�ional CITY P Tel.No.
tha parmif is for ono hundred dollan(f100)or I�as.) pLqN CHF.CK
I ceni(y rhat in ihn performance of ihe work for which rhis APPIICANT
permi�is issued,I shoil ne�r.mploy any pe�son in ony manner
se ns�o becomv subjact to Ihe Workers'Compensotion Laws. ��9ti���9 Fislures F�rs�20 ADDRESS
Torol No._� Addirionol
CITY Tel.No.
Date Applicont Fi.ed Applfonces Not Over 1 HP pE�,,,,�i
NOTICE TO APPIiCANT: If, ofter mok�ng rhfs Cnril(icote of APiKICANT `� '
Exemption, you shauld hncnme subjec� to the Workeri Ro^9e_Hea�er_D.W._
Compenso�ion provisions cI the lobor Code,you must forth- Oven —Dryer —W.M._ ADDRESS ?n 921, AVENrnA AMAPOLA
wi�h tomply with such provisions or Ihis permit sholl be. Top —FAU _W.H._
deemr,d revoked. Hood _Fan _O�hr.r_ CITY EL TORO Tel.Nog59-8108
LICENSED CONTRACTO45 DECLARATION ii:F`„iE OR
I he.reby oHirm iticl I om licensed urder provisions of Chopter 9 Disp. _Room Air Cond. — REG.NUMBER 4 3317 4 Class. C-10
(commenNng wfth Sectfon 7000�of Divlsion 3 of the Business powar Apporotus 8 Lorge Apoliances DISTRICT NO. PROCESSED BY �
�nd Prnfessions Code,ond my�itPnse is in full force nnd efiect.
Sire 8 Typr.HP,KW,KVA,or KVAR O � O
License Number 433174 i;�.aoss C-10 uP�0 1 Incl. F�NAL �
eo,,,,��,o.WATMAN ELECTR� o�e.i��10 Incl. DATE � rt 7 �:� VALIDATION p
❑ o�e,io�o so i�d. r-
FINAL
I om PxPT�I Uf1dP.I Sec. Over 50 l0 100 Inc. BY �N�f`�_�_ �
B.BP.C.for�h�s reoson �ve��� e� 2
Dn�c: Services,Swbd.,MCC 8 Ponelboards ►
0-700 Amp.Under 6Q1 V
Siqnafure 201-1000 Amp.Under 600 V
❑ Over 1000 Amp.or Ovr,r 600 V
Eaemption in�Reg.fdnint.Ele:�.
SI":GL:FA!J.:LY Temp.Power Pole 8 Appurtenances
��OA^E OVlNER-BUILDER DECLARATION Sign wclh One Brnnch Circuit
I tiereby ofli.ri rhar I ar�r..empt Lor�ttie Con�.acrer's L�cense :°�$.1:.�ri
law(or�he followinq reason(Sec��on 7031.5,Rus�ness and Add���ervl 5�;�9•anch Circui�x .
Professions Code): . . • •�
� M�sc.Condvi�s 8 Conducrors '•
1,os owncr of ihc prep=ny,will do rhe wcrk and ihe � • •7 r,J�
struc!ure is not in!end�d or olfered for sale(Section Other�SPP CORI�IIPIP FPP SChFduI2�� ,
7044,Ausiness ond Prof>ssions Code). � � ���; ���-
CCNSTRUCTION IENDING AGENCY �
I hereby o(firm ihat there is o cons'ruci�on lending ogency for � i.G J—��� �
the performance of ihr.work for which thiz permit is issued PER.MiT FEE (S�b•To�nl)
�Sec.3097.Civ.C.�. •
PIAN CHECKING FEE
Lende.r's Nome
PERMIT ISSUING FEE /D S
Lr.nder's Address
I cenf(y thn�I Fo�e rend t6is applico��on vnd s�ni=iF�ot!he TOTAL FEE "f�s
above�nlormation is corrr,cr.I oqree�o comply with oll Co�nfy
ordinontes ond Sr '�lows reguln��np El�cn;tol wirinq,ond
hereby au! ri eprrsr,n!aliv�s o(ihis County to enler upon .
the a n ioned pr pPr�y r i ectlon purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
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