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WORKERS'COMPENSATION DEClA4ATION ,�A�� �0�9� qpp��CATION FOR ELECTRICAL PERMIT
I hereby affirm ihat I ha�e n certilicotr. of consen�ro self �E'� �
��su.P,o.o ce�rificoie of Wo�ke�s'Compensaron Insuro�ce, CQUNTY OF LOS ANGELES ,�"3 BUILDING AND SAFETY
or.a ceriifi=d copy thereaf(Set.3�00,Lr,b.C.)
roucy No.761 JB1�C17��1�� IRM INS BROKE �
❑ y FOR A�►IICANT 70 Flll IN CDRES.
Cer��f�r.d copy is hereby(urnished. New Residenfiol BIJgs.8 Pools EA�H Np. �EE
� Cerlified capy is(iled wi�h�he coun�y building inspec- I 8 2-famlly,Sq.Ft.--y/��— E — S LOCALITY DIAMOND BAR
lion deperim t. Multi•(am�ly Sq.FI.�JGL�_L — r tiEnvEST AV
Dc�e�Applitom WA�1�N ELECTRIC J�esidemial Swimming PoolsT
CRO55 ST.
UWNE4 Ok
��� / F:RM NA.ME
CERTIFICATE OF E%E-MPTION FROM WORKERS' Ou�leis:Rec�Light�Sw.L MAIL
COMPENSATION INSURANCE aCDaESS 4600 CAMPUS DRIVE
(Thi�s�etion nasd no�ba eompl�e�d li fha work Inrelwd by Firsr�0
ths ps•mif ia fe�en�bundred dollon(5100)or Isss.) Total No. Additionol atAciEWPORT BEACH Tr,l.NoS40-0500
'I cerr�fy�F.o�in ihe per(ermnnce of itie werk lor which this aAN CHECK
ermit is issuPc�,I s�+all nol P.m �o on l�7PlICANT
� p y y person in any monner
so as b become subjec��o rhe Werkers'Compnnsntion Laws. Lighiing Fin�ures First 40 ADDRESS
To�ol No.�_ Addi�ianal
Dore- epplicant CITY Tel.No.
NOTICE TO APPLICANT: If, afier moking ihis Certificote o( Fixr.d Applinnces No�Over 1 HP I'E4MiI �
F.emption, you should become subjeci io the Workeri Rangr._Heo�er_D.W._
naaicl,Nr WATi1AN ELECTRIC INC
Cnmpenso�ion p.ovisions ol�he Labor Code,you musl forrh- Ovxn _Dryer —W.M.— ADDRESS Z�(�21 A�]�hIDA AMAPOLA
wi!n comply wi�n such provisions or this permil shall be Top _FAU —W.H._
deemed�evoked. Hood _Fon _O'her_ CITY EL TORO Tel.No.859-8108
LICENSED CONTRACTORS DECLARATION t�:ENSE OR
I hereby offirm Ihnt I om I�censr.d under provisions of Chople�9 Disp. _Room A�r Cond. — R[G.NUMBER 433174 Closz. C-1�
(comriencing with Seciion 7000)of Division 3 of ihe Business p�w,er Apporotus 8 La�qe Appliances DISTRICT NO. PROCESSED BY }
and Profess�ons Code,a�d my I�censr,is tn full ferce and eHecL �
Sire 8 Type HP,KW,KVA,or KVAR l� �,�
license Num�er 433174 ���.Class C_lo Up lo I Incl. FINAL V
Con�racror WATMAN ELEC�'��e Over I io 10 Incl. DATE J � /p i/ yALIDATION �
Ove.r 10 l0 50 Ind. 6 f� �
FINAL ~
I am ezempl under 5=c. Over 5p to IOD In[. BY 'n V
B.&A.C.fcr this rcoson
Ovor 100 ;>?�-^Y� 'R� y
Services,Swbd.,MCC 8 Ponelboards , Z
�0��' 0-200 Amp.Under 600 V
SignnWre 201-1000 Amp.Undor 600 V '
aOver 1000 Amp.or Orer bpp V
Exemprion ior R�q.�^,�inr.Elecf.
SINGIE FAMILY ;em Power Pole 8 A
H0:'E O:VNER�BUIIDER DECLARATION �' ppurlennnces
Si�n with One Bronth Circ�i� ?O II�C�
I hereby nffirm Ihol I om e.empt{rom Ih�Comrocior's License q�����onol Siqn Brnnch Circui�s
Law fer�F�follc•n-ing recson�Sec'icn 7031.5, 6usiness and
Professions Cnde)� �t• • • s •2
❑ I,as ownr,r of the M,sc.Condulis 8 Conductors � � �,�Q 3 0
prcperty,will do thc work and the
s!r�cture is net intend=d oi olf=red for snle (Section Oiher(See Comple�e Fee Schedule)_ ,
70ee,Business nnd Professions CodeJ. • • "7 G.3 9�i
CCNSTRUCTION IENDING AGENCY O��O�`H�l
I hereby afNrm ihoi!here is a construction lend�ng ogency for
ihe pericrmantc of the work ior which rhis permit is issued PERMIT FEE �Sub-To!al)
(Sr,c.3097,Civ.C.�.
PLAN CHECKING FEE
Lr.nder'S hame �
PERMIT ISSUING FEE � ��Q
tendcr's Add�ess
I certify�ha�I havr read this appi�cor�on and sra+e�hot�hP TOTAL FFE ��•�9
cbovr.inferma��en is corcecr.I ngrec rn tomply wirh nll Counry .
ord�nonces and •e laws regulatfng Elec�ricol wiring,and
her�by ou or' representa�ives of this County lo enter�pon �
the ntioned property to inspection purposes. SEE REVERSE FOR EXPLANATORY IANGUAGE
'iG � / ��/
$ign ure.of P min�e Dale '
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