HomeMy WebLinkAbout0843A (4) WORKERS'CO.MPENSATION DECLARATION 7.SA663 �o�p� APPLICATION FOR ELECTRICAL PERMIT �
I hr,reby affirm ihn�I havc a cen�Rmte oi mnsonr to seH �F'fl�'
insure,or a ce�tifica�e o1 werke�s'Compensauon tnsurnnce, COUNTY OF LOS ANGELES �'�BUILDING AND SAFETY
or n cerGfied copy Iherrof�Sec.3800,Lob.C.)
D�YNo761aTB1O]�omA��Y I� INS BROKE FOiAVVLICAMTOFIIIIN �b
�y� Cr.�ri�=d copy is hr,�r,by IurnisF�ed. New Residentiol Bld9s.8 Poals EACH NO. FEE ACOaES. � ' � '
p�� Ceriified copy is f�led wi�h ihe county bu�ld�ng inspec- 1 8 2-Fomily,Sq.Fi. f = 5 IOCALITY DIAMOND BAR
I"r �ian de art e Mul1i-family Sq.FI. NfnREST
—Q �j cacsssT. DIAMOND BAR & GRAND AVE
��Q wA1'�N ELECTRIC Residen�ial Swimming Pools Own�ER OR
Daie. Applicon � PRESLEY OF SO CALIF
FIRM NAME
CERTIFICA E OF EXEMPTION FROM WORKERS' p� L � hWit
Ouilets:Ret_Liqht Sw.
COMPCNSATION INSURANCE m ADDaFSS 4600 C�PU.S DRIVE
This�ecNon n��d no}bs com I�}�d if tho work inrolvad 6 First 20
� P Y Toiol No. Additional CITY NEWPORT BCH Te�.N�540-0500
tha parmll I�lor one hundred dollars(SI00)or las�.)
I cr.riify 1h�1 in�hr�r.r(orr�nnrr.oF�hr.work for which ihis AVPNCANTK
permit is�ss�ed,I sF�ll no�employ any pe�son in any manner
so as�o become s�bjeti ro�he Wo�keri Compansa�ion Laws. L�gh��ng Fi.lures First 20 ADORE55
To�al No._� Additional
CITY Tel.Mo.
Da�e Appliconl fi.ed Appliancas Not Over 1 HP PfRMIi
NOTICE TO APPIICANT: If, ofler moking �his Cr.r�ifitate of AVPLICANT WATMAN ELECTRIC
. Eeempi�on, you should become subject to tF.e Workers' Ronge_Heater_D.W._
Compe.nsalion p�ovisions oF Ihe lo6or Code,you mus�for�h- Oven _Dryer _W.M._ ADDRE55 ZpgZ7. AVENIDA AMAPOLA
wi�h comply wi�h such provisions cr ihis permi� sholl be 7op _FAU _W.H.—
deemed revoked. CITY Tel.N �
LICEhSED CONTRACTORS DECIARATION Hood _Fan _Orher_
D�sp. _Room A�r Cond. — ���N�� Cla
I hereby oHirm�h�t I om licensed under provisions of Chopler 9 REG.NUMBER 43 3�.7�I s�-1�
(comr�encing w�ih Setrion 7000)of D���sion 7 of�he Business power Apparotus 8 lorqe Appl�onces DISTRICT NO. PROCESSED 8Y }
ond Profess�ons Code,nnd my I�cense is in(ull iorce ond e!fect. 1 O d
Size 8 Type HP,KW,KVA,or KVAR { �
License Number 433174 lic.ClossC�l� FINAL V
Up lo I Incl.
WATMAN ELECTRI� o�a.i io 101nc1. DAIE �� �/a�� YAIIDATION °C
Controc�or �� Over 10 ta 50 Incl. O
❑ F INAL
I om exempf undor Sec. Over 5p to 100 Inc. BY u�
.cl�i �i,� LL,
B.BP.C.for this reasan Ovar 100 � �n
Services,Swbd.,MCC 8 Ponelboords , U =
Dnr=: 0-2f70 Amp.Under 600 V
S�gnorure 201-1000 Amp.Under 600 V
❑ Over 1000 Amp.ar Ovar bOQ V
E�empiion!o�Reg.fAa�nt.Elect.
S!":GLE Fn"1`.!:Y Temp.Power Pole 8 Appurlenance5
HOME OWNER-BUIIDER DECLARATION Sign with OnP 9rnnch Circuit �
I hernby nFRrm rho�I e^�e,eripi frori�he Cem•ocror's License. Addi�ionol Siqn 8ronch Circads '
law fcr ifie follow�ng reason(Sect�on 7031.5, Bus�ness a�d .r'Q�(1.3�i
Profess�ons Code): �
❑ I,as owner of�hr prooerty,will do thn work ond ihe Misc.Cond�i�s 8 Conductors �!e � � � �2
s�ructurr. is nai in+ended er oflered for sa!e�Seciion OtFe.r(See Comple�e Fee Schedule)_ ,
7044,Business ond Prafessions Code�. � �� • •�:�/�� J
CONSTRUCTION IENDING AGENCY .� • •[;C � j�,`T-,
I hnrr.by nffirm rhar�here is a consrruction lending agency ior
�hP p�rformonce of the work fo�which ih�s pe�mi�is issurd PERMIT FEE (Sub-ToialJ Q �,(�j—8[!
(Sec.3097,Civ.C.).
PLAN CHECKING FEE . .
Lrtnder's Namr.
PER.MIT ISSUI'JG FEE �
LP.lItIP!5 At�d�P.55
I cerlify thot 1 hove reod Ihis application and s�a!e that�he TOTAL FEE
obove informe��en is conect.I o3rer.to comply wi�h nll Counly ,
ardinnnces nnd 5 Io Inws reguln�inq Elrcirical wiring,and
hereby au c representatives of�his County to en�cr upon
tFe a �m r !ioned propert for"nspeciion n„�ncses.
+ � � `^r� SEE REVERSE FOR EXPLANATORV IANGUAGE
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