HomeMy WebLinkAbout0837A (4) LVORKERS'COMPENSATION DECIARATION 76Ah63 iDi81 '
I hr.�e6y affirm 1Fnl I h�ve.a certifica�e o�consent f0 Sel( �E-� APPLICATION FOR ELECTRICAL PERMIT j�
i�su.e,o�a cer�if�co��of Vforkers'CoR+pensotlon Ins��once, �pUNTY OF LOS ANGELE$ �'a BUILDING AND SAFETY J�
or o cernhed cr.py rhereof(Sec.3800,Lob.C.)
P❑olicyNo.7�i1JB1O�P��y IRM INS BROKE FORA/►LICANTiOFILIIN JUB �
Ce�tifi=d copy is hereby fu�nisl+ed. EACH NO FFE ACDRF55
New Res�dential Bidgs.8 Pools s _ s DIAMOND BAR
�(Certifiad copy is filed wi�h Ihc counly huildfng inspeo- �g�-Family,Sq.Ft. — LOCAt1TY
tionde orim i Muili-fam'I S Ft. � ��"� (i/ NEnRE51
p "� 'Y Q� cRoss sr. D R GRAND AV
Dote '�`� ppP������WATI''I�.N EL�CTRIC Residenilal Swimminq Pools
O'NNER 04
�j�.f'/��j fIRM NAME
CERTIFICAT OF EXEMPTION FROM WORKERS' Ouile�s:Ret�light�Sw.� MA!L
COMPENSATION INSURANCE - n6DaE55 4600 CAMPUS DRIVE
Thit�actlon na�d nel b�com lefed if�h�werk involved 6 First 20
� P Y ioro�No.� A�i�i;,;o„o� � � c�Tv NEWPORT BEACH ie�.No540-0500
�h�p�rmit��lor ons hundr�d dollor�(3100)or I�t�.) PLqN CHECK
I cerrify thot in th�perfo.mance af thr,wo�k for which this A�7pCANT
perm�l is issued,I sholl no1 ern�loy nny person in ony m�nner
so as�o hacome subieU�o ihe Wcrkers'Compensotion Lows. Li9hnng FiKtures Firsl 20 ' ADDRESS �
' To�ol No._� Addiiional
CITY Tel.No.
Date Applicanl Fl.vd Applionces Not Over 1 HP PER.M.II
NOTICE TO APPLICANT: If, ofter mo4ing �his Certifico'e ef nPPLICANT
Eremp+ion, you should becemr, subjec� ro �he Workers' Range_Hea�er_D.W._
Cempensa��on p.o��slons ci ehe LnF,or Code,yov mus�io.rh- Oven _Dryer _W.M.— ADDRESS Zpg21 AVENIDA A.^1APOI,A
�th comply fh such prov�s�ons or ihis permif sholl be Top —FAU _W.H.— CITY Tel.Nog59-8108
I deemed rrvoked. Hoed _Fan _O!her_
IICENSED CONTRACTORS DECLARATION uCFtiSE OR
I he.oby af�irm thet I am lirensrd under provisians o(Chap'er 9 Disp. _Rocm Air Cond. — R[G.NUMBER 43 3174 Closs. C-1�
(commr.ncing with Seclion 7000)of Division 3 oi the 8us�ness power Apparoius 8 Large Appliantes DISTRICT NO. PROCESSED BY r
o�d Preiessions Code.,and my license is in full ferce and eHect. p,
Size 8 Type H?,KW,KVA,or KVAR Q �
L�cc�sc t�luR+ber433174 ��c.Class C—�'0 FINAL
Up to l Ind.
Over I 10 10 Incl. DATE `/� � d� VALIDATION �
ConrracrorWATMAN ELECTR�.',� O�er 10�0 50 Incl. �
� FINAL ~
I om e.empi onder Sec. Over Sp l0 100 Inc. BY �7 W
B.BP.C.for Ihfs reason Over I00 ,��""`t%'��J N
Services,Swbd.,MCC 8 Ponelboards � U ?
Dair.: 0-200 Amp.Under 600 V
S�qna�ure 401-1000 Amp.Under 6W V
❑ Over 1000 Amn.Or O�er 600 V
E.r.m�!ion lor Rn�.1.loint.Elrt�.
$INGIE FA�,AILV Temp.Power Pale 8 Appur�e.nonces
H0.'dE OWNfR-RUILDER DECLARATION r �
I hereb offirm ihet I om ezem t from rhe Sign wi!h One 0ranch Circuii ..O S�%A
y p Ceno-acror's licensrt Addi!iennl 5� n Prnnrh Circuirt
law fer ihe fe!!o•xi.^.�recsen(Section 7031.5, 6usiness and � ti� � � � �� �
Pro(essions Code�: ,
❑ I,ns awner of ihe p�epr.rty,will do rhe work and the Mlsc.Conduits 8 Conducfors � � ����G
srruc!u�e is not iniended er e(fered tor snle (Seciion O�hrr(See Comple�e Fee Schr.dule)_
70�4,B�sine!s and Pro(essions CodeJ. , e s •(;c�,£i J�
CONSTRUCTION IENDiNG AGENCY G 1.D 3—8 4
I hereby af(irm ihor ihere is n rnnsauc�ion lending c9ency for �
thr,pr.rformonc�of the work for which Ihis permit is issued PERMIT FEE (Sub-Tn�ol)
(Set.9097.Civ.C.).
PLAN CHECKING FEE
Lender's Nr.me
PERMIT ISSUING FEE /Q
LCI1�P.��S A(�(IlP55
I certily�ha�I ha�e read�his nnpl�ca�ion and sta�e iha�ihe TOTAL FEE lj�i• cQ�
obove in(ormn�ion is correc�.I agree lo comply with all Caun�y
ordinances ond St�te lo�+s re,��a��n�Elec+r�cal w�ring,and
herr.by au!ho�i e r eseMo�ivos o(�his County to emer upon
ihe obove.- ed preper�y(or� spec' �����o,Ps.
/✓ � SEE REVERSE FOR EXPLANATORV IANGUAGE
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