HomeMy WebLinkAbout0830A (4) LNORKERS'COMPENSATION DECLA4ATION 76A56J i0i61 '
1 hrrchy oifirm ihai I hove a rertificatP o(conseni l0 5e�< <E.� APPLICATiON FOR ELECTRICAL PERMIT �
tnsure,cr a ce�i�iica�e ot Workers'Compe�sa�ion Insuronte, COUNTY OP LOS ANGELES .g y BUILDING AND SAFETY
or a certiFied capy iheree!(Svc.38t7J,Lnb.C.)
Ocv r�,6.l�I$1.Q1�compa�y I M TNS RRnKF.R FOR APMICAM f0 Flll IN �oe `
Cr,rtiiir,d cory is hereby furnishr.d. EACH NO. FEE AD7RC5. �
New Rr.sidential Bldgs.8 Pools
�Cort�f�ed topy is filed wi�h the county bullding inspeo- I 8 2�Fomily,Sq.Fi. f — 5 LOCAIITY DIAMOND BAR
w i�on deparime�i M�IIi-lomily Sq.FI. — hEn4E51
LdATMAN ELECTRI Residenriol Swimming Pools c�oSs Sr.DIAMOND E€�R & GRAND AVE
Da�e '� � nPPl�cnnr yy�(.� fOjQMNA°,ae PRESLEY OF SO CALIF
CERTIFICATE OF E%EMPTION FROM WORKERS' � MA'L 4600 CAMPUS DRIVE
COMPENSATION INSURANCE Outle.is:Rec�Lighi � Sw. nC�RE55
(Thls�eetlon n��d ne�6�eomplafad if}h�wo�k invelv�d by Firsi ZO
tha parmit is(or one hundrod dollors(SI00)or Iws.)
To�al No. Additional ��TM?�IEWPORT BEACH r��.Ng40-0500
PLAN�HECK
I cer�ify that in�he pertormnnce of thr.work for which this q?PLtCANT
permil is issue�i,I sholl nol emplpy pny persan in ony monner
so os�o br.cor�e suhje:i to the Workers'Compensation Laws. Lighiing Ft.iures F�rs�40 ADDRESS
To�al No._� Addiiional
CITY iel.No.
Dote Applicont Fixvd Applipnces Nol Over 1 HP
NOTICE TO APPLICANT: If, afler making this Cer�ifica�e of n�ucnrWATMAN ELECTRIC IN�,'
Exemp�ion, yau should be.come subjeci ta fhe Workeri Range_Heorer_D.W._
Comrens�i�on prov�s�ons of Ihe Ln6or Code,yo�m�st fonh- Ovan _Dryer —W.M.— A��RESQO92Z AV��IDA 11.M.�P��
with comply w'th s�ch �;�ovisions or �his permit shall be Top _FAU _W.H._ $S9—H�.OH
deemed revoked. Hond _Fan _O�her_ CIT`�I+ TORO CA Tel.IVo.
IICENSED CONTRACTORS DECLARATION �i"„��
I here6 rflirm i!•a�I om IicensrJ�nder P Oixp. _Room Air Cond. _ 4 3 31.�J�} C-1Q
y. provisions o(Cho �e�9 PEG.NUMBER
Class.
(cammencing with Sect�on 7000)of Division 9 of�he Business power Apparot�s 8 Large Applionces DISTRICT NO. PROCESSED BY �
ar.d ProEessions Ccde,ond my license is in full fnrte ond eHett. �7 �
Size 8 Type HP,KW,KVA,or KVAR /� /�2-Ct-�e'T.-L� O
License Number 433174 u�.uos�-10 u�,ro I Incl. FINAL u
WATMAN ELECTR�� Over I fo 101nc1. DATE � (� 9� yq��DAT10N Q
Comrocror Over 10 io 50 Ind. � �
� FINAL
I om e.eript�nder S�c. Over 50 to 100 Inc. BY �� VL yVi
8.8P.C.fcr�his�eason �""�� v�i
Services,Swbd.,MCC 8 Panelboards S . Z
Date: 0-200 Amp.Under 600 V
$iqnoiurc 201-1000 Amp.Under 600 V
� E.emp!ion ior Rr.q.h',aint.Eleci. Over 1000 Amp.or Over 600 V
5!NGLE FAi4!LY Temp.Pownr Pole 8 Appurlenances =_O�S�J.O A '
HO!�AE OVJNER-BUILCER DECLARATICN Sign wilh One Brnnch C�rcuit �
I herrby affirm�Fe�I n�n r,zPmnf Irom�ti?Con�rnc�or's licente i� � � � � �2
law fer:he following rcason(SeUion 7031.5, Businesz ond '°'�`�110"'��'���R""`-h C�*cv�!s '
Prcfessionz Code): � • � � �.•Z 5
❑ I,as owne.of the preperly,will do II�P wo�k ard ihe M�st.Conduiis 8 Conductors T
siruc�urr, is not inrended or effered iei sale�Secrion Other(See Complr.rr.Fee Schr.dule)_ ► • • � � C�.c J u
7044,Business and Prclr.ssions Code). 0,.O 3_II 4
CONSTRUCTION LEN�:NG AGENCY
I hereby nlfirm thot�here is n construcfion lending agenty tor
ihe performance of ihe work fer which�his permit is issued PERMIT FEE �Su6-io�al)
(Sec.3097,Civ.C.).
PLAN CHECKING FEE
Lnndr.r'S Nome
PERMIT ISSUING FEE
Lender's Address
I cor�ify thnt I ho�e reod ih�s opplicaiion and s+oie�ho�itie TOTAL FEE
above informa�ion is co•rect.I ag�e^�o comply with oll County � � �
ordinances ond a�e laws reg�lo�ing Elecirical wiring,ond
hr.reby ni � 'e represrnlniives o(�his Counly lo en�er upon �
+hr. n�ion�d rope iy! �nsp=c��on=u.pose� SEE REVERSE FOR EXPLANATORY LANGUAGE
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