HomeMy WebLinkAbout0842A (4) V�ORKERS'COMPENSATION DECLARATION 76.4669 iO�Ei 1
I hereby oN�rm,��,I have o«���f;«f�af�o�5e��„5��< <E�� APPLICATION FOR ELECTRICAL PERMIT �
ins��e,o�a ce��7+cai�of wo�kers'Compensa+ion�nsurancr„ �pUNTY OF LOS ANGELES �� BUILDING AND SAFETY
er o certified cepy tF.ereof(Sec.3800,Lob.C.)
P❑olicyNo761JBlQ�mp�ny I� INS BROKER FORA�PIICANTiOFIILIN JOB �,Vj . yf-
Grrlifir.d copy is hereby furn�shPd. New Residenliol Bldgs.8 Pools EACH NO. FEE
A��RESS�.Xu( TT
�Ce���f�ad conr is filed with�he coumy buildtng inspec- I&2-Family,Sq.Ft. S = S �OCA��TY DIAMOND BAR '
lion[�Bpo��ment Multi-fnmii FI. YEARESf
y�' cRoss sr. DIAMOND BAR & GRAND AV
Resideniial Swimming Pools
Date ` � ` nPplimnt WATMAN ELECTRIC OwNEROR
(n��p �. • FIRMNAME PRESLEY OF SO CALIF
CERTIFICATE OF E%EMPTION FROM WORKERS' `� � � L � MA�L
Ouileis:Rec L�gh� A Sw.
COMPENSATIpN INSURANCE First 20 3 ADDRFSS ,
(Thif sMion n��d net b�complal�d if Ih�work Inrolr�d by Toial No. ��� Addi�ional ��TY NEWPORT BEACH iel.No.54 O—O$O
1hs permlt Is lor ona hundr�d dollars(5100)or le�s.) PIAN CHfCK
I cerlify thot in thr,periermonce oI Ihe.work for which this APP�I�ANT
permit is issued,I sholl nol amploy ony pe�son in any manne.r
so as�0 6acor�e subje:r ro the Workers'Companso�ion Laws. Ligh�ing Fi.lv�r.s Firs�40 ` ADDRESS
To�al No. � Addilional
CITY Tel.No.
Dote Applicent Fi.ed Appllances Nol Over 1 HP
NOTICE TO APPLICANT: IF, oflei moking rhis Cerrificale o( ��Mii
E.emption. you should hecome. subject io rhe WorGers' Ronge_Hea1e/_D.W._ FF^�ICANTWATMAN ELEC,'TRI�.' INC
Cemrenso�ion provisions of�he Lobor Code,you must forth- Oven —Dryer —W.M.— ADDRE55
wllh comply wlth such provisions or this permil sholl be 7op —FAU _W.H._
deemyd revoked. Hood _Fan _O�hr.r_ CITY EL TORO Tel.hlo.BS9-810
IICENSED CONTRACTORS DECLARATION Disn. _Rocm Air Co�d. — ��`E��O4 Closs.
I herw6y of(irm rti�t I am licensed under provisions of Chopter 9 RfG.nIUMeER
(cornmencing w�th$ection 7000)of Dlvislon 3 oF ihe Business po,wer Apporo�us 8 Lorqe Appliances ' DISTRICT NO. PROCESSED BY �
and Pra'essions Coda,ond my I�cense is in(ull(orce ond effeu. �
433174 , C-10 Size 8 Typr.HP,KW,KVA,or KVAR �� 0
License Num6er Lic.Closs Up to 1 Incl. FINAL V
Over 1 ro 10 Incl. DATE � �� ��L VAIIDATION �
Contrauor WATMAN EL.EC�&,�C Over t0�o SO lnd. � �
❑ FINAL �
I om e*empr under Sec. Over 50 to 100 Inc. BY� �7 ,�� w
l.� ��'`' O.
6.87.C.Tor Ihis reoson Over 100 �' Z
pa��, Serv�ces,Swbd.,MCC 8 Paneiboa�ds ►
0-200 Amp.Under 600 V
Signnture 2p1-1000 Amp.Undxr 600 V
❑ Over 1000 Amp.or Over 600 V
EaempYon for Reg.f.",aini.Ele.ct.
5!NGLE FP.M!LY Temp.Power Pole 8 Appurlenances �
HO"J�E OWNFR�BUIIDER DECLARATION S�gn wi�h One Branch C�rcuit
I hereby o(firm�ha�I om nxrm�l from Ihe Con�r�c�oi s licrnsA Addii�nnol Si�n P.rnnch C�rcui�s
Law icr Ihe followinp reason(Sr.c�ion 70�1.5, Business and :�C a A,2 J�1
Professiors Code.�:
❑� I,os owner of the pronerty,will do ihe work nnd Ihe Misc.Condui�s 8 Conduc�ors �; . a • • •�
s�ruchirr, is nof inrended or olfe.ed for sale(Section O�he�(See Complete Fee Schedule)_
7044,Ausiness and Pro�essions Cede). ► � • •5 9.7 8
CONSTRUCTION IENDInG AGENCY , e e ��,(;;�;
I hereby a(lirm Ihal Ihero is n conshuc�ion lendint��genty fer
�hr.performancr.oF thr.work!or which this permit is�ssued PERMIT FEE (5�6•Toiai) 0 �.��—�ll
(Sr.c.3097,Civ.C.).
PLAN CHECKING FEE .
Lender's Nomr, �
PERMIT ISSUING FEE .
Lender's Add•ess
I terti(y thnt I hovr,rcad�i,�s�nn������o��nd sia�e�hal Ihr. TOTAL FEE
obove inlo�molion�s correct.I ng�ee to comply wi!h nll Couniy
ordinonces and �aie lows rer,ula+�ng Elecn�cal w�ring,ond
hereby nut' ropresentolives oF�his Counly lo eNer upan
ihr a niioned prn,ne iy for inspeuion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
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