HomeMy WebLinkAbout0828A (4) WORKERS'COMPENSATION DECLARATION 76n5a3 IOiel 1
� hereby afE�rm ttio�I havn a cerlificale of�o�SP��,o,e�, �E� APPLICATION FOR ELECTRICAL PERMIT �
insure,or a cenif�co±e o(Wo�kers'Compensaiion Insuronce, COUNTY OF LOS ANGELES 8'� BUILDING AND SAFETY
or o ceri�(ied copy ihereof(Sec.3800,tnb.C.�
Poi��v No. 761 T�1 O�Q,��„Y_IR'K INS BROKER FOR APPLICANT TO FILI IN JOB
� Cr.rti(iPd co�y�s herehy iurnished. EACH NO. FEE ADDRESS � ' �'
New Residenrial Bldgs.8 Pcols
� Certified copy is flled wi!h ihe,county building inspec- 1 8 2�Family,Sq.Ft, E — S LOCALITY DIAMOND BAR
tion dP.porl e . Mulli�(amily$q.Ft. — NEARESi
WATMAN ELECTRIC Residen��olSwimmin Pools c4osss�IAMOND SAR & GRAND AVE
Da�e — � Appliconl � 9 UWNERO�gF,SLEY OF SO CALIF
FIRM N0..
CERTIFIC E OF El(E.MPTION FROM WORKERS' Outleis:Rec Light�Sw.�
COMPENSATION INSURANCE � ADD4ESS 4600 CAMPUS DRIVE
(7his�ectlon n��d nof h�cemplafad ii 1h�werk fnvolvad by L First 20
fhe permit It►or ona hundrad dollnrs(SI00)or In�.) Toral No. Add�tional CITY NE P RT BEACH r°� "540-0500
PIAN CNfCK
I certify ihat in ihe periormonce nF fhr,work for which this qaatKaNi
permil is issue�l,I sholl no1 Pmploy ony person in any manner
so os�o batome subject to the Workers'Compansalion Laws. Li9hlinq Fixtures First 20 ADDRESS
Total No._� Add�rion�l
Doir. opplicant CITY Tol.No.
NOTICE TO APPLICANT: If, nfler moking rhis Certi(icaie. of Fired Apoliances Net O�er 1 HP PFRMiI
E.empron, you should become subiect io the Wo�ke�i Range_Heater_D.W._ APRiCANTWATMAN ELE�.'TRIC INC
Cempe�so��o�p�o��s�o�s oF ihe Lobor Code,you mvsr(o�th- O�en _D�ye� _W.M._ ADORE55 20921 AVENIDA AM7�,POLA
ith tompty with s�ch provisions or this permi� sholl be Tnp _FAU _W.H.—
deemedreveked. Hood _Fon _Other_ CITY ieI.N�59-8108
IICFNSED CONTRACTORS DECLARATION I::EN,[OR
I here6y oHirm rhnl I om licensed under provisions o(Chopier 9 Disp. _Raom Air Cond. — REG.NUMBER Class.
(cornr�encinq with Section 70b0)of Division 3 oF Ihe Business power Apporofus 8 Lorqe Appliances OISTRICT NO. PROCE55 BY }
and Vra!essions Coda,nnd my Ii�Pnse is in lull force and effecl. (� y
Sire 8 Type HP,KW,KVA,or KVAR ��]
License Number 433174 i;�,po„C-10 uP ro I In[I. FINAL �
WATMAN ELECTRI,�' O�er 1�o 101nc1. DATE r3 "?G�j �(7[,L VALIDATION �
Contmcto �� Over 10�0 50 Incl. �
� FINAL
I em exempt�r.der Se.c. �O�e.50�o IOO lnc. BY ���n� �
8.8P.C.for this�ecson Ove.100 N
► $
Services,Swbd.,MCC 8 Ponelboords
Date: 0-1(10 Amp.Under 600 V
S��noture 201-1000 Amp.Under 600 V
❑ Over 1000 Amp.or Over 600 V
EFempiion for Rr.�.f.loint.Elecl.
S!NGLE FA!"JlY Tem Power Pole 8 A
r. ppurlennnces
hi0!J.;OVJNfR�BUILDER CECIARATION Sign wilh One Bronch Circuil
I hereby effirr�ihet I am rxemnf fr�m�he Con�•acrer's Lic�nse q�dirio�al Si Rr!fnch C+rcui�s Q�,y•Z&{{
low!or�hc fol;owing rcason(SeU�on 703I.5, Business and �"- ;'s
Professions CedeJ:
� M1sc.Condu��s 8 Conducro�s i� • • • • •Z
I,os ownor o�ihr.properly,will do ihe work cnd the
s�ruciure is no�imended or offered lor soln(Sec��on Other(See Complete Fee Schedulr.�_ ► ' � �1 �z�
7044,Bus�n�ss and Pro(r.ssicns Code).
' CONSTRUCTION LENDING AGENCY • • • � C.G S�;
I hereby affirm thot tht!ro is a tonslr�cfion lendin�oAency(or Q�.b:l—L3 11
+he performance of the work for wh�ch�his prrmit is issuetl PERMIT FEE (Sub-To�nl)
(Sec.3097,Civ.C.). �
7lAN CHECNING FEE
Lender's Nomc
PERMIT ISSUING FEE � `a
Lender's Address
I cenily ihal I hnvc read�his applicarion and sta+c Iho1�he TOTAL FEE
obove info�mallon h correcL I a�•er.fo comply wilh all Counly
or�linontes n� �re lows regul�iing Elec!rical wiring,�nd
hcreby a n,rr,pro<ento!�ves o(�h�s Cooniy lo enter upon
ihe C- PlltiOflP[I�lCn rry( ilIS�P.C�iDn purpose/s�.,/ SEE REVERSE FOR EXPLANATORV LANGUAGE
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