HomeMy WebLinkAbout0833A WORKECS'COMPENSATION DECLARATIDN �t��� �0�81 APPLICATION FOR ELECTRICAL PERMIT �
I herr.by afVrm that I ha�e a cenilicme nF consen�io self �E-�
insure,or�certi(icale oF Workers'Compensa!ion�nsuronce, COUNTY OF LOS ANGELES .�3 BUILDING AND SAFETY
or a certiGed copY ihvrr.of(Sec.3H00,Lob.C.)
O�YNo�]C)Z�TBZOLtJ�mp��yIRM INS BROItERS FORAPPII[AM70�Ill�N CDRE55
Cer�+i�ed cony rs hereby(umished. New ResideNiol Bidgs.8 Pools EnGH NQ FfE
1 8 Y-Fomii Ft s — S LOCALITY D BAR
�Cerlified mpy is f�lnd with the couniy building insp6c- 1'•�' _
lion deportmer.t Muhi•family Sq.Fl.� � c4ossssr. DIAMOND BAR & GRAND A V
//"" Residential Swimming Poo�s �
oa�e//!��_��ApplitorVliATMAN ELECTRIC '� F!RM NAME PRESLEY OF SO CALIF
CFRTIFIC�TE OF EXEMPTION FROM WORKERS' put e s:Rec�l�ght�5w.,,L_ nCDeESS 46 00 CAMPUS DRIVE
COMPfNSAT10N Ih15URANCE First 20 -"'n
(This s�cfion n��d nol bs complrfad i(the work inrolr�d by To�ol No.� Additionol c�Tv NEWPORT BEACH iel.No.S 4 O—O S OO
th�permk it ier one hundrad dolfors(3100)or tass.) / PLAN CMECK
I cernfy iF.oi in itie performance of ihe work Ier which th�s aFpuCaNT
permil is issued,1 shoil nni ampfoy ony person in ony mnnner ADDRFSS
so as to become subjett rv�Fe Workers'Compensarion Lnws. li9hlin5�Fixlures Firsl 2p
Additianal
Total No. CITY Tel.No.
Do!e Applimm Fi.ad Appl�onces Nm Over 1 HP vfrt,Mit
P10TICE TO APPUCANT: If, oiler moking �his Certif�cote of � APPLICANT WATMAN ELECTRIC INC
E.emp�ion, you sho�id become subjeci �o �he Wor4ers' Range_Heo�er_D.W._...
Compensa+ion prov�s�o�s o(ihe tabor Code,you mvst forih• Oven_Dryer —W.M._ ADDRESS 20921 �'AVF.NIDA AMAPOLA
wiin campiy wiih s�ch provis�ons o* this permit sholl bc Top —FAU —W.H.— CITY EL TORO CArel.N859-8108
deemedrevok�A. Hood _fon _Other_
LICENSED CONTRACTORS DECLARATION LICChSE GR
I I�ere6y o(�i.m ihni I om I�censrd unde�p�ovisions o1 Chapte�9 Disp. _Room A�r COnd. — R(G.NUMBER 4 3 3174 Class. C�
(commencinp wiih Sec�icn 7000)of Divisicn 3 of the Businass power Appo�cius 8 Large Appl�onces DISTRICT NO. P ESSE BY y
ond P�oless�ons Code,nnd riy I�:ense is in f�ll force and AHact. `Q O
9 3 3174 C—].0 S'=�8 TyPP kP•KW,KVA,or KVAR
License Numyr,r Lic.Clnss Up�o I��cl. FINAL V
Over 1 to 101nc1. DATE �? �L� G(7G� VAItDAT10N Q
comracro� WATMAN ELECTI�I�C �
Over 10 fo 50 Inil. FINAL U
❑ I om exempi under Sec. Over 50�0 100 Inc. B� �� �1 d
Over 100 C // w
6.8P.C.for this reoson Z
Dotr.� �+����es,Swbd.,MCC 8 Ponelboords �
0-�00 Amp,Under 600 V
Signet�re ?Ol-1000 Amp.Under 6p0 V
❑ Over 1000 Amp,or Over 600 V
E.emp�icn fo•Reg.1."�inr.Elecr.
SINGIE FAMqY Temp.Power Pole 8 Appurienonces
HO'l.E OVJhER�BUILDER DECLARATION 5����„�ih One 9rcnch C�rcuit
I hereby nffirm ihol I am c.r.mpl hom�he Conhoc�oi sLirentn n C�3�J F
Addiilenal S�gn Branch Ci�co��s
low�e•��+^lel!av�ir.q recscn(Section 7031.5, Business and r:• • • • •L
Prefess�ons Codr)�
❑ �,as owner af ihe M�sc.Condui�s 8 Conducio.s � � �7 Q�9
prop=rty,will do the work and�he p�hc� Sxe Com iete Fee.Schedvle— ,
strvc�o�e is not iniended or o4fered(or sale(Sec��on � P � �
70ed,Business nnd Proless�ons Code). • • •7 r J�/�'
CO4STRUCTION IEND WG AG{NCY O L�J—II�l
I herehy offfrm rhai rhere is n consnud�on lendfng ogr.ncy For
Ihr.per(o�monce of�he work for which rhis pr.rmil is issue.d PERMIT FEE (Su6-To�ol)
(Sr.c.3D97.Civ.C.).
PLAN CHECKING FEE
lrnder's Name
PERMIT iSSUING fEE /O �
Lender's Address
I certify that I hnvr.recd fh�s opplim�ion and sia'e ihot rhe TOTAL FEE /JD� �
above inic�ma�icn is ccrred.I agrce�o camply wiih aIi Coun�y
crd�nanccs ond S+a� laws re9ulanng EleUrim)wiring,and
hereby oWh ue. presen�a!ivws oF tnis Cou��y�o enier upon
ihe obo oned property f r in euicn po�poses. SEE REVERSE FOR EXPIANA�ORV IANGUAGE
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