HomeMy WebLinkAbout0846A VJORKERS'COMPE�vSATIONDECLARATION 76�� ��,R� APPLICATION FOR ELECTRICAL PERMIT �
I hnreby cffi.m Ihat I h�vr. a cc.lificale of consenf lo se�l �E"��
insure,er n ceriifica�e of Workers'Compe�saran��sura�ce. COUNTY OF l05 ANGELES �.'� BUILDING AND SAFETY
or a certlf�ed copy thereo((Sec.3800,Lab.C.)
P❑ollcy No.ZY1L�I.YNUnpany IRM INS BROKER FOR APPIKANT TO FILt IN �U� {, ,
Ccrfified copy is hereby furnlshed. New Residen�iol Bldgs.8 Pools EaCH NO. FEE aCortE55 .J r
� Certified copy is filed wi�h the coun!y building inspec- 1 8 7-Family,Sq.Ft. _ = S LOCAIITY DIAMOND BAR
tion do a��m.n Mulli-lamily$q.Ft. hinRES
� caoss�IAMO:VD BAR & GRAND A�
Do'e-1�Applica�n7ATMAN F. . . TRIC Residenlial Swimming Pools OWNFR OR
�(� fIR.M NA
CE4T�FICATE OF EXEMPTION FROM WORNERS' Outlers:Ret�Light�Sw./ ' MA��
CO.MPENSATION INSURANCE ACDRESS 4600 CAMPUS DRIVE
This��ctlen n��d nel b�tem I�I�d il th�nerk involv�d b Ffrst.20
� P Y Totol No. Addi+ional CITY Tel.No
�he psrmit 1�for ona hundrad dollan(5100)or len.) -
I carY( �h�t�n ihe (ormonce oi ihe wo�k for wh�ch th�s PLAN CHECK
Y Pe� APPLICANT
�r.rmil is issued,I shall nol xmploy ony�erson in ony manner
so os�o become subject�o ihe Wor4eri Compenwlion laws. Li9hting Fixfures First 20 ADDRESS
Add���onol
To7ol No. . CITY Tel.No.
Do+e APP�Icani Fi.ed Applionces Not Over 1 HP pERMif
NOTICE TO APPL!CANT: If, af!er making �his Certificate o( A�IIUNT WATMAN ELECTRIC INC
E.empticn, yau shnu�d becomP subjnct ta Ihe. Workr.rs' Ro�ge_Heo�er_D.W._
Compensn!ion orovisions of�F.e Lnbor Code,you musl forth- Oven _Dryer _W.M.— ADDRESS 2�(�Z1 AVENIDP. �'�iP �l
wi!h comply with such provisions or �his permii sholl be Top —FAII —W.H.—
deemed revo4ed. Hood _Fan _O�her_ CITYEL TORO CA Tel.No$59-8108
LICFNSFD CONTRACTOR$DFCLARATION tiCE!JSE OR
I hereby aHirm!hol I om licensed under provisions of Chop�er 9 DisP. _Room Air Cond. — RFG.NUM6�3 3174 Class(�-10
(commencing wi+ti Seciion 7000)of Divis�on 3 of�he Bus�ness pa,�,er A o�us 8 lor e A I onces DISTRICT NO. PROCE D BY �,
and Pro�wssions Code,and riy I�cense�s in full force and effec�. �O` g PP� d
$irn 8 Type.HP,KW,KVA,or KVAR �O O'v`p- Q
l�cense t�7umber 433174 ���,ClossC-10 FINAL u
Up l0 1 Intl. DATE
WATMAN ELECTRI�' over��o�o�nc1. �� � ,,f�� VALIDATION p ,
Contro:!or a�� Over 10�0 50 Incl. FINAL V
❑ I am exer�pt unde.Sec. Over 50�0 100 Inc. 81' �-}�C
Over 100 v// ���µL�J N
B.BP.C.(or th�s reason Z
Dare: Services,Swbd.,MCC 8 Ponelboards ►
0-2W Amp.Under 600 V
Signoture Y01-1000 Amp.Unde�600 V
❑ Ovxr 1000 Amp.or Over 60p V
E.empiion for Reg.Maint.Elec�.
SINGLC f„MILY Temp.Power Pole 8 App�rienonces
HOME OWNFR�BUIt�ER DECIARATION S;q�w;!h One Bronch Circuit
I hereL•y c!(irm tf�cl I om erempl Irem rhe Centroc�or's Literse t,. ��th Ci�c����s ['
Addi�ioral_i:,�R. I a i
Law(or the Iollowing renson�Section 7031.5,Business and -�� ��'f�
Professions Code):
� M�sc.Conduiis&Conducro�s `�� ° � � �2
I,os own=r of the preper�y,will do ihe wcrk and the
struciure is not in'ended or o((r.red icr sa!e (Sec�ion ��hr.r(See.Comple�e Fee Schedule)— ► � • .lt a b F3
7D44,Bus�ness and Prof=ss�ons Code).
CONSTRUCTION IEh�ING AGENCY • • ���.b%?u
I here6y affirm rhat there is a tonsiruction lend�ng ogency(or ��.n J'�7 4
th�pe•fr,rmance of the we�k for which Ihis permil is issur.d PERMIT FEE �Sub-Toral)
(Sec.3097.C�v.C.J. �
PIAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE
IC�tIC��S A4�(��f'SS
I cerrify iho�1 hove read�h�s acp��caron ond staie�hat�he TOTAL FEE
above informarlon is correct.I a9ree io comply with all Coun�y
ordirnnces and r, lows rPr�uloling Eleclrical wiring,nnd
hereby ou o�' represen!ativt!s of Ihis County la e.nfer u{�on
thr. - nlio�^d p[epr.r y inr i peclion purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
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