HomeMy WebLinkAbout0845A (4) WORKERS'COMPENSATION DECLARATION 76A663 �a�a� APPLICATION FOR ELECTRICAL PERMIT �
I he�eby af��rm thot I h�ve n cr.rtifica�e of censr.nt 10 self �E��
insu�r,or o cer�i(ica�e of Workers'Compensatian Insurance, COUNTY OF LOS ANGELES G��j BUILOING AND SAFETY
or arernhed cepy ihr.recf�Sec.3800,Lab.C.)
P❑Olicy No.���Fwny TRM TN.ri RRfIKF,}Z FOR APPLICAM TO FILL IN ��B � '
Cerliiied copy�s he�eby�urnistied. EACH NO. FEE nCDRE55
New Residenliol BIdgS.8 Pools
�pG7�� Cer�i(ied copy is filed wi�h the counly building inspec- 1 8 2-Fnmily,Sq.FI. 5 — S LOCALITY DIAMON� BAR
/-- tion deparlme�r, Mulfi•family Sq.FI. � — NFAREST1pIpMOND BAR & GRAND AVE
WATMAN ELECTRIC Residemiol5wimmingPools CRp555.
oa�e ! � Applicani / �[ owr+ea o��SLEY OF SO CALIF
I `�/'/7�� FIRM NA
CERIIFICATE OF E%EMPTION FROM WORKERS' Oullets:Rec�lighl I Sw..�, MAiL
I COMPENSATION INSURANCE 3 /CDRE55 4600 CAMPUS DRIVE
Thif�ecften n��d nol b�tem I�f�d if 1h�work Involrsd 6 First 20
I ( � Y To�al No. Addiiionnl CIT Tal.No. _
the permif it For onv hundrod dollon(5100)or I�ss.)
I ce.rlif hat in ihe fermorce.of the work for which this RAN CHECK
Y� Pe` APPL!CANT
permit is issued,I sholl not employ any person in ony manner
so as�o become subip«<o rhe Wo�kr,rs'Compenw'ian Lnws. Lighting Fi.iures First 20 ADDRESS
To�al No.� Add��ional
CITY Tel.No.
Dn•e Applicanl Fi.ad App�ionces No�Ovrr 1 HP PERMIT
NOiICE TO APPIICANT: If, after making lhis Cnrtificare of APVLKAN7 WATMAN ELECTRIC INC
Exemp��o�, you should become s�bject io ihe Worke�s' Ra^9e_Heo�er_D.W._
co.-;.o-:�':c,;• .•��s:s+�e!:bo•code,yo�_m�•��e��ti- Dven _Dryer _W.M.— ADDRESS 20921 AVENIDA AMAPOLA
��h cemply �th�such provisions or �his permit�shall be Top —FAU —W.H._
deemed revoked. Hood _Fan _O�her— CITY T�i.N859-8108
IICENSED CONTRACTORS DECLARATION ���r^5E pq
I hereby aHirm�tio�1 nm litenswd under provisions of CFop�er 9 Disp. _Room Air Cond. _ RFG.NUM6fR 433174 Class.C-1�
(commoncing w�th Section 7000J of D���sion 9 of the.Business DISTRiCT NO. PROCESSE Y
and Prolessions Code,and my license is in fuil force and effec�. Power Appornrus 8 lorgr.Appiianres � � 6
Size R Type HP,KW,KVA,or KVAR �� Q
Licr.nse Number d���7d Lic.Clas�'��n V
Up b 1 IncL FINAL
Com.acroWAT AN F.T. . -TRT�ie Over 1�o t01nd. �ATE 1/ ��/�c/ VpLIDATION �
r Y
❑ Over 10 to SD Incl. FINAL ~
I am exempt u�der Set. Over 5010 100 Inc. BY �' �
� �,C�..?-s2
8.8F.C.ior this r�ason Over 100 Z
Do�c: Services,Swbd.,MCC 8 Ponalboords ,
0•�00 Amp.Under 6W V
S�gnature 201-1000 Amp.Under 600 V
❑ Over 1000 Amp.or Over 600 V
Er^ropilen fe�Reg.�vtai�L Elecr.
$INGLE FAMILY Temp.Power Pcle 8 Appur�enances
HO.'dE OWNER-9UILDER DECLA4ATION Sign wiih One.&anch Circuii :'G�C�A
1 herrby nffirm thoi I om e.empi(rom the Conrrocfor's l�cense q�+dition�l$ign Bronch Cir:�iis :.'• • • s •'J
Law for ihe following reoson(Sec�ion 7071.5, Businoss ond •�
P�OfP55iOn5 CO()P,�:
� M�st.Condui�s 8 Con�uciors � • •J 3 � l�
I,as owner of ihe preperty,will do ihe wo�k and the
structure is no��n!ended or olfr.rr.d for sale�Secrion O�her($ee Comple�e Fee Schndulr,)— , � � ` �� C-
U
7044,Busi�e<5 ond Profr.ssions Code.).
CONSTRUCTION IENDING AGENCY O �,O v��G�l
I hereby affirm thnt ihe.re is a construd�on Iend�ng ac�ency lor
the perfermonce o(�he work fo�wh�ch th�s perm�i is�ssued pERMIT FEE (Sub-Toinl)
(Sec.3097,C�v.C.).
PLAN CHECKING FEE .
Lendcr's Nnm.
PERMIT ISSUING FEE �
lrnder's Address
I certify�hot I hove rend thiz applica�ion and sia�e that ihe TOTAL FEE ���
above informolien is correc�.I a�ree io comply wi•h nll Cauniy
erdinances and S� e I�ws rer�ulnting Elec�ricol wirin�,ond
hercby aui : rtpresen�atives of ihis Counly lo enier upon
�1�e o . r .ioned proncrry( .i�s c�ion nu�posr.s. SEE REVERSE FOR EXPLANATpRV LANGUAGE
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