HomeMy WebLinkAbout0844A WORKERS'COMPENSATIONDECLARATION 76Ane3 IOi91 APPLICATION FOR ELECTRICAL PERMIT �
I hereby nffirm !hnl I hnvr. a certiFicote of consenl 10 self CE�806G
insure,er a cr.riilicair.of Werke.rs'Compensotion Insuro�ce., COUNTV OF LOS ANGELE$ C'a BUILDING AND SAFETY
nr n�ertified copy lherecf�Set.3800,Lab.C.) '
' O�YNo 7GZ�TBZO�R�Pa�Y IRM INS BROKER FORA►VlIC11M70FILLIN .108 n
CP�IiIiP(�CO�1y is hcreby(�rnished. New Res�deniial Bldgs.8 Ponls EaCH NO. FEE /+C��E55 � p( �
� Certified copy is filed with the county building inspec- �g 2-Family,Sq.Ft. 5 = S IOCALITY DIAMOND BAR
lion dPporfine i Multi-ipmily$q.Ff.� � NEARE51
Res�deni�olSw�mmin Poo�s caosssTAIA.'NOND BAR & GRAND AVE
� Dnre,��=���4nPlicnn�WATMAN ELECTRIC � 9 o•.vNezocPRESLEY OF SO CALIF.
I ����� FIRM NAME
I CERTIFICA E OF E%EMPTION FROM WORKERS' O��lats:Ret�Light�Sw.� M'41� 9600 CAMPU DR
COMPENSP.TION INSURANCE '3 ADD4F55
I Firsi 40
(Thl�txlion na�d no16�compl�f�d if 1h�work inrolved by � CITY NEWPORT BEACH Tei.No54�—�500
th�permi}it lor ons hand�ed dellon(f100)er lefs.) To�ol No. Additianal
II cr.rrify thn�in ihe.perfermonce of thr.work for whfch ihis qrpuCqNTK
pa.m��is Iss�ed,I sholl net employ ony person in ony monner
so as io become subjeci to ihe Workers'Compensotion laws. Lighting Fixtures Firs�20 ADDRE55
Addi��onol
To!ol No.� CITY Tel.No.
Da+e �Appl�cont Fixed Applionces Not Over I HP ��MiT
NOTICE TO APPLICANT: If, o('er mokinq �his Cxrl�f�co�e of APPIICANT WATMAN ELECTRIC INC.
E.empr;on, you should become subject to the Workers' Range_Heo'er_D.W.—
Comnensa��on o�avisions nf�he Lobnr Code,�nu must iorth• O�en _Dryer —W.M._ ADDRESS
i�h comply wi�h such provisions or ihis permii sholl be Top —FAU —W.H.— CITY EL TORO CFl —
rlremed revoked. Hood _Fon _0!her_ Tel.No.
! LICFNSFD CONTRACTORS DECIARATION LiCFNSE OR
I he�eby o!firm thnt I nm licensr!under provisions of Chap�er 9 Disp. _Room Air Cortd. — REG.NUMBER 433174 Class. C-10
(cemmxncing wifh Secrion 7000)of Divis�on 3 of Ihe Business Power Appa•a�us 8 Large Appliances DISTRICT NO. PROCE D BY }
and Prolessions Code,and my license is in full force and ef(ect. p,
Size 3 Type HP,KW,KVA,or KVAR t Q
Liccnse Number 433174 ���,ClossC_lo FINAL ' V
Up 10 1 Incl.
WATP'IAN ELECTF�C O�er I io 101nc1. DATE i! � �r�l yp��DATION Q
Conhac�or ��e Over 10�n SO IncL FiNAI , •� V
❑ I am e.empt under Sea Over 50 to 100 Inc. BY �r-� �• �, w
B.BP.C.for ihis reoson Over 100 v/7 �'u / Z
D''�: Services,Swbd.,MCC 8 Ponelboards ► �
0-?00 Amp.Under 600 V
� Sign�lurr. �Ol-1000 Amp.Under 600 V
I ❑ Over 1000 Amp,or Ovar 600 V
E.emption for Reg.Moini.E�ecr.
S1':GLE FA!l,ILY Txmp.Powr,r Pole 8 Appur�enances
HCME O�h'NFR�BUILDER DECLARATION S�gn wiih Onr.Br�nch C�rcu�� � �
I he.e6y offirm�hn�I nm ex^mp�L•er+ihn Conaac�o%s Urense Add�i�on�l S�qn Hr�nch Grcu�ix ^C r�,4 A �
low for ihe(ollow�ng renson($ec��on 7031.5, Rusiness ond
Prcfessions Codc): j;. • • .2
❑ I,as ownr.r oF ihe preperty,will do the work and the M,sc.Condui�s 8 Conductors '•
s�ruc�ure is nci inrended or clfcred fcr sole (Sr.ction O'her(See Complete Fee Sched�le)_ ► � e •�i 0,� J
70e4,Business nnd Proicss�ons Code). � —
. •�L�.� J i.i
CCNSTRUCTICN IENDING AGENCY
I hrrr.by affirm�hol lhere is o consirut�ion lending agenty ior � �.Q J—�}/�
ihe per(orm�ncr of Ihr.wark for which this permi�is issued PERMIT FEE (Sub•Tatal)
(Set.9097,Civ.C.). .
PLAN CHECKING FEE
Lendr.r's Namc
PERMIT ISSU�NG FEE
Lender's Add�e.ss
I cr.rt�fy�hat I havr.rr,od ihis applicaiian and s�ate tho��!+e TOTAL FEE 15
above inlormaiien is correU.I ogree.io comply wlth all Coun�y
ordinances anrl fn`r Inws rr.qul�ling Elec�rital wirinq,ond �
he.reby nu cr' .re�rr.sen�alivss o(ihis Counly fo enler upon
the .ntioned�reperi for inspe.ct�on purposes.
' SEE REVERSE FOR EXPIANATORY LANGUAGE
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