HomeMy WebLinkAbout0833A (4) 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�YNo7C)Z�TBZOL�J�mp��yIRM INS BROItERS FORAPPII[AM70�Ill�N CDRE55
CerRi�ed cony rs hereby fumished. New ResideNiol Bldgs.8 Pools EnGH NQ FEE
1 8 Y-Fomii Ft s — S LOCALITY D BAR
�Cerlified mpy is f�lnd with the couniy building insp6c- 1'•�' _
��on deportmer.t Muhi•family Sq.Fl.� � c4ossssr. DIAMOND BAR & GRAND A V
Residentiol Swimming Poo�s �
oa�e//!��_�ApplitorVliATMAN ELECTRIC '� F!RM NAME PRESLEY OF SO CALIF
CFRTIFIC TE OF EXEMPTION FROM WORKERS' p��y;Rec�l�ght�5w.,,L_ nCDef55 46 OO CAMPUS DRIVE
COMPENSATION INSURANCE First 20 -"'n
(This s�cfion n��d nol bs complrfad i(the work inrolr�d by To�ol No.� Add�no�ol c�Tv NEWPORT BEACH iel.No.54 O—O S OO
th�permk{t ier one hundrad dolfors(5100)or lass.) P�AN CMECK
I cernfy iF.oi in itie performance of ihe work Ier which th�s aFpuCaNT
permil is issued,1 sholl nm ampfoy ony person in ony monner ADDRFSS
so as to become subjett rv+Fe Workers'Compensarion Lnws. li9hlin5�Fixlures F�rs�20
Additianal
Total No. CITY Tel.No.
Do!e Applimm Fi.ad Appl�onces Noi Over 1 HP vfrt,Mit
P10TICE TO APPUCANT: If, ofter moking �his Certif�cote oi � 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(�he labor Code,you mvst fo�ih• Oven _Dryer —W.M._ ADDRESS 20921 �'AVF.NIDA AMAPOLA
wiin campiy wiih s�ch provis�ons or 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�ereby 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 Business 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 forre and AHact. `Q O
9 3 3174 C'—].0 $i=c 8 Type HP,KW,KVA,or KVAR
License Numyer Lic.Clnss Up fo I IncL FINAL V
Over 1 to 101nc1. DATE �? nC� G(7G� VAItDAT10N Q
comracro� WATMAN ELECTI�I�C �
Over 10 fo 50 Incl. FINAL U
❑ I om exempi under Sec. Over 50�0 100 Inc. B� �� �� d
Over 100 C // w
B.BP.C.fOr this rroson Z
Datr.� �+����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.Elec�.
51NCIE FAMI�Y Temp.Power Pole 8 Appurienon[P5
HO'l.E OVJ�;ER�BUILDER DECLARATION $i��wilh One 9rcnch Grcuit
I hereby nffirm ihol I am e.r.mpl hom�he Controc�oi sLicentn n C�3�J`�
Addinenal Sign Branch Ci�co��s
low�e•I�+^lel!vv�ir.q recscn(Section 7031.5, Business ond r�• • • • •L
Prefees�ons Codr)�
❑ �,as owner af ihe M�sc.Condui�s 8 Cond�cio.s � � �7 Q�9
prep=rty,will do the work and fie p�hc� Sne Com iete Fee.Schedvle— ,
strvc�u�e is not iniended or offerr.d(or sale(Sec��on � P � �
70ed,Business nnd Proless�ons Code). • • •7 r J�/�'
CO4STRUCTION IENDING AG{IJCY O �.�J—II�l
I herehy offirm rhal rhere is n cons�ruc��on lending 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 cenify ihot I hnvr.reed fh�s opplica�ion and sio'e�ho�ihe TOTAL FEE /J D� �
above iniama�ien is cerred.I agree�o camply wiih aIi Coun�y
crd�nanccs ond S�a� laws re9ulanng Elec�rim)wiring,and
hereby oWh ue. presen�a!ives oF tnis Cou��y�o eNer upon
ihe obo oned property f r in euicn po�poses. SEE REVERSE FOR EXPtANATORV IANGUAGE
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