HomeMy WebLinkAbout0841A WORKERS'COMPENSATIONDECLARATION 76A563 �o,a, qpp��CATION FOR ELECTRICAL PERMIT
I ha.rehy oftirm �hnl I hov=a certifirn�c of tonsuni 10 sel( CE�Fl06C' �
insure,or a cerufico�r,oI Workers'Compensaron I�s��ronco, COUNTY OF LOS ANGELES �� BUILDING AND SAFETY
or a cerlified cepy thereef(Soc.3�700,Lab.C.)
POol�icy No.761JBZO�p��Y IRM INS BROKER FOR APPLICAM i0 FILI IN JOB �� �(„
Cerlified ccpy is hereby furnishpd. EACH h0. FEE ADD�E55 /�l
I�1 New Residem��l Bldgs.8 Pools
�y�,�„Ce��ified copy�s i�lPd w�tti ihr,counly building inspet- 1&2-Fomily,Sq.FI. s = E LOCALITY DIAMOND BAR
trrrn �ion deperlmen�. Mulli�fomily Sq.Ft.�p�, NFA4ESi
cRosssT. DIAMOND BAR & GRAND
Residentiol Swimming Pools PRESLEY OF SO CALIF
Da�P. Applica�'1IATMAN F.i.R!'TRTC` �/ry' ORMNAME
CfRTIfICATE OF E7(EMPTION FROM WORNERS' puil�R��Light�5w./ �"U"�
COMPENSATION INSURANCE F,5 � � ADDRF55 4600 CADSPUS DRIVE
(Thia sattion n�sd nol b�eemplefed if fha work inrolr�d by To�al No.� Addii�onol CITY NEWPORT BEACHTei.N�40—0500
the permit is for one hundrad dollan(5100)or Isss.) —
PLAN CHECK
I certify Ihat in!hP performon�e oi thP work for which�his AP7LfCANT
permil is issued,I sholl nol er�ploy o�y person in ony mannr.r
so os�o F.ecor�e subjec�io ihe Workers'Compensation laws. Li9h�ing Fiztures Firs�20 ADDRE55
Total No.� Additional
CITY Tel.No.
Datr. Appliceni Fixed Applionces Not Over 1 HP
NOTICE TO APPLICANT: II, after moking ihis Cerii(icn�e of i'tkMii WATMAN ELECTRIC IN�.'
EzempGon, yov shoutd br.mr�e subject fo the Worke�s' Ronqe_Heater_D.W._ /+�uGnNT
Com�ensa�ion provis�ons of ihe Lo6nr Code,you mus�foriV�- Oven _Dryer _W.M._ ADDRESS ZQ9Z1 AVENIDA �MPPOLA
inc �omply wilh such provisions or Ihis permit sholl he Top _FAU —W.H.—
deemed re�oked. Hved _Fan _O�her_ CITY Tel.No.
IICENSED CONTRACTORS DECLARATION u::fti5c Oe
1 heraby oHirm itiot I nm licensed�n�er provisions of Chopter 9 Disp. _Rocm Air Cand. — REG M1UMBE�A 3 3174 Class. C-16
(commencinq wi!h Secl�on 7000)of Divisicn 3 01 the Business p�,�,er Appara�us 8 Lorge Applionces DISTRICT NO. PROCESSED BY }
and Prn.nssions Code,and my li:en5e is in full lorce and eNect. �
� 433174 (,'-1Q Sire.8 Type HP,KW,KVA,o�KVAR 1� Q
License Number Lic.Class Up 70 1 IncL FINAL V
Conrraci�AT�N ELECTRI�ie Ove�I ro 101nc1. DA7E �' �7 �� yp��DAT10N �
❑ Over 1010 SO lncl. V
I em e•empt unde�Sec. FINAL
Over SO l0 100 Int. BY /1
B.BP.C.for this reoson O�er 1p0 I '�""�C���� Z
pa�n; Servicr.s,Swbd.,MCC 8 Panelboards .
0-?W Amp.Undar 500 V
S�GnnWre 201-I000 Amp.Under 600 V
❑ Ovar 1000 Amp,or Over 600 V
Ezemp�:on(o�Reg.A!aint.Eiect.
SINGLE FA^.!!LY Temp.Powar Pole R App�rtenantes
HOM.E OVJNER-BUILDER DECLARA710N
I hP.eby nffirm�hct I ar�eKrtmp�from�hn COM•C.CIC�5 LIC?OSP $ign wi�h One B�anth Circuil '
La��v for the following reoson(Secuon:031.5, Business and A��'��onol S�gn A�an�h C��cviis � �:C b�� i�.
Professions Code): �
❑ I,ns owner ef ehr praperly,will do 1he work ond the Misc.Con�luits 8 Conduc�ors � e • • •i
struc:ure is noi inrended or oflered for sale(Section ��her(See Comple�e Fee Sched�le)— , � + •J G.,�s
7044,Bus�ness ond Piofessions Code).
CONST4UCTION LEN�!NG AGENCY e .
•J�i. /i���
I here.by nflirm thof ihere is a cons'ruc�ion lerding a�r.ncy ior
the performancr of th�wo�k for which iliis pe�mi�is issund PER.VIIT FEE (Sub-To�nl) � �.��—'3!l
(Sec.3097,Civ.C.).
PLAN CHCCKING FEE
Lrnder's Nome
PERMIT ISSUING fFE
Lender's Address
I ceriily t�+ot I havr,reod ihis o�plica�ion nnd s�ore Ihol Ihe TOTAL FEE
obove in!ormorlon is correcl.I aqree to comply wilh all Couniy � •
ord�nances and 5� e lows regula��ng Electr�col wiring,ond
h=rehy nufh ri epresr,n�ar�ves of th�s Coumy b enrcr upen
ihr.ob • me �onad pro r.rry or� spect�on purpeses. SEE REVERSE FOR EXPLANATORY IANGUAGE '
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