HomeMy WebLinkAbout0847A (4) WORKfRS'COMPENSATION DECLARATION 76n663 IO�BI I
I herrby of(irm ihot I hnve n certificalr of consent to,��< <E.� APPLICATION FOR ELECTRICAL PERMIT �
��sure,or o cerli(ica�e of Workers'Compensation Insurance, COUNTY OF LOS ANGELES /�'�I BUILDING AND SAFETY
ar n.certifir.d cepy�hereof�Sec.3800,Lnb.C.)
O�Y No II6I�TBZO��Q P��Y 1� jNS BROKE FOR APPLIGM TO Fltt IN JOB
CPlli(iP.(I(C�Y is hereby furnished. EnChi NO. FEE ADDRESS 0
New Res�demial Bldgs.8 Pools
�CP��i{iPCI CO�Iy is(iled wi�h Ih�counfy building insp�a 1 8 2-Fomily,Sq.Fi. S — S LOCALITY I
lion department. Mulli�(omily$q,Ft. J�rI.S — r ' ^+FANESi Djp�jyOND BAR & GRAND AV
CRO55 ST.
,�VATNIAN ELECTRIC Resideniial Swimm�ng Pools
Da�e ^ Applico � OwNER GR
CERTIFICATE OF EXEMPTION FROM WORKERS' �rq��� � F�M Na.�E PRESLEY OF SO CALIF
COMPENSAiION INSURANCE Ou�lets:Rec ligh� F'r55w�.� 3 � ppqE55 4600 C�PU$ DRIVE
[This�Kfion nNd nef ba complNed if Ih�work inrelr�d by Total No.� Additionol CITY NEWPORT SCHr��."°.54 0-0500
1ha parmil Is!or ona hundrod dollon(5100)or Issi.) FtpN CHECK '
I certify thot in ihe performance of Ihe.work for which ihis APPLICANT
pe�mil is issued,I sholl nol employ o�y pe�son in ony monner
so os�o bncome subject to ihe Workeri Compensa�ion Laws. Lighring Firiures+� F�rst 20 � � ADDRESS
Totol No. O'� �4ddilional
CITY Tel.No.
Date Applican� Fi.ed Applionces Nof Over I HP
NOTICE TO APPL!CANT: If, ofter moking rhis Cerli(icate o( qppM�[A47 �/�TA�j'�j�j ELECTRIC INC
E.emption, you should hrcome subjec� to ihe Workers' Range_Hea�er_D.W.—
Compr.nsn��on provisions cf the Lnbor Code,you must iorlh- Oven _Dryer _W.M.— ADDRESS
ith comply 'th such provisions or Ihis permit shall br. Top _FAU —W.H._ $L TORO C�a 859-8108
deemed re�oked. CiTY Tel.No.
LICENSED CONTRACTOR$DEC�ARATION Hood _Fon _Other_
Dis _Room Air Cond. _ IICENSE OR `+�lo
I hereby affirm Ihnl I am�i:rnsed under provisions of Chapter 9 �' RfG.NUMBFR Closs.
(cor�mencing with SeUit;n 7000)of Oivision 3 0(�he Business power Apporatus 8 Large Applionces DISTRICT NO. PROCES D BY }
and Professions Cnde,ond my lice�se is in foll Ierce ond eHec�. /�� 6
Sirr.8 Type HP,KW,KVA,or KVAR �V �
License Number 433174 i;�.�ios: C-10 UP'o� nCI F�hA� �
co�,��c�o�WATMAN ELECTR�a� o�P�i�0 10lncl. D4TE j � 7 �5L yp��DAiION p
❑ Over 10 to SO Incl. H
I om e.en+pt�nder Sec. Over 50 to 100 Int. BY A��/> yf W
B.BP.C.(or this racson Ovar 100 L���-Z�zns �— �y
Services,Swbd.,MCC 8 Paneiboards l Z
Datc: 0-200 Amp.Under 600 V � �'C'�� � ��
S�gnoiure �01-1000 Amp.Under 600 V y• . . . •2
❑ O�ar I D00 Amp,or Over 60p V
E.r,m�rion for Rsq.Pllain�.E;ect. ' � ���,7�
ct'�!G!E FP.M!LY Temp.Powe.r Pole d Appurtenances
HO�ME OV.'NER-BUIICER DECLARATION S�gn wiih One Brcnch C�rcuii • o e{;?)%,�
I here,yy affirm ihr.t I ar�r.xemp�from 1hr.Con�rot�or's Litens!t p�{�{itionol S��n Rrnnch C��cui�s
law for the followinq rcason(Seclion i^u31.5,ousine.ss ond ��.(1:J�cq,�A
Prolessions Code):
❑ I,os own�r of ihc Misc.Condui�s 8 Conduciors
Q rcpe�iy,will do�he work and rhe Other See Com lete Fee Schedulr,_ ,
54tK!llfP is no�in�_nded or offered for salr. ($ection ( P �
7044,Buslness ond ProFr,<sions Cede).
CONSTRUCTION IEhDING AGENCY �
I hereby c((irm thal there is a conshuction Ir.ndin9 agency fer
the performance of ihe work fer which this permii 7s�ss�ed PER.MIT FEE (Sub-io�al)
(Set.3097,Civ.C.).
PIAN CHECKING FEE
lender's Nome
PERNIIT ISSUING FEE �O v
Lender's nddress
I certify thol I hove rr,nd�his r.pplicotion ond s�a�n that�hr. TOTAI FEE G�Q��
above�nformalion is correct.I egren lo comply wiih all Couniy
ordinances and �ate�ows regula�ing Electriccl wiring,nnd
hr.reby au ori .rr,presen!�tives of this Counly lo enlcr upon '
thc ntionnd ryeper y for nspec+�on pu�posns. SEE REVERSE FOR EXPIANATORY LANGUAGE
��r���
Signotu e of P .ninr,r. Dale
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