HomeMy WebLinkAbout0829A (4) YrO4KER5'CO•NPENSATIONDECLARATION 75p�� �0�81 APPLICATION FOR ELECTRICAL PERMIT �
I he�eby aff�rm tho� I have o cr.rtilim�e oF conseni�n self CE�806G
��s�.e,or a cerrl(knie of wo�kers'Compensa+�on Ins�rnnce, COUNTY OF LOS ANGELES �� BUILDING AND SAFETY
�r�cernhed co�y ihr,rpof(SPc.3800,Ln�.C.)
Po��c No. 761JB10�Q, IRM INS BROKER
❑ y pany FOR A►►IICANT 70 flll IN �08 ��y7
Certified copy is herehy�urnhhed. New Residentiol Bidgs.8 Pools EaCH NO. FEE nDDrtE55 JP�
�Cer�ified co�y is filnd wilh the county build�ng inspet- 1 8 2-Family,Sq.FI. E — 5 LOCALITY DIAMOND BAR
�ion departme � Mulli-fomily$q.FI, — NEFPEST DIAMOND BAR & GRAND AVE
CROSS ST.
Reslden�tal$wtmming Pools
oaie " � app�icam WATMAN ELECTRIC ��,� RM NA!NE PRESLEY F S ALIF
CERTIFICA7 OF E%EMFTION FROM WORNERS' Outle�s:Rec.[�Light�Sw.L �"A��
COMPENSAiION INSURANCE ADDRESS L] " AMP S I E
7his�setion�a�d no1 b�com Iri�d it Ih�wo�k Inrelved 6 Firs�70
� P y Toial No. Add�ttonai c�td�IEWPORT B ACH Te�,No.540-0500
fhs permil ft lor ons hundrad dollars(SI00)o�I�ta.) PIqN CIaECK
I ce.riiFy ihai in the perforrsance ol the wo�k!cr wh�ch�h�s APPLIC�NT
permit is issued,I sholl not r.mploy ony person in any monner
so as�o berome su'.�jecr ro the Workers'Cempensolion Laws. lighling Fiwlurrz / F�rst 40 ADDRESS
Tolal No. Addilional
CITY Tal.No.
Date Applicant Fixr.d Appliantes Not Orer 1 HP �Rr.��I
NOTICE TO APPLICANT; If, of�er making �his Cerriicme nf APPIICP.NT WATMAN ELECTRIC INC
Exemp�ion, you should F.etome wbjecl In Ihe Wo�keri Range_Heote�_D.W._
eo-+;,�-�,o+:-,�,-o•::::�-:��•�_!�t�,e^de.,,_ :.s!rc•!h- O�vn _Dr�rr _W.M._ ADDRESS 20921 AVENIDA AMAPOLA
wiih comply ��h s�ch provisions or Ihis permif shall be Top �FAU —W.H.—
deemed revcked. CITY Tel.IV
tICEYSED CONTRACiCRS DECLARATION Hood _Fnn _Olher_ —
Disp. _RoomAirCond. _ ���E~�� 433174 cio:s. C-10
I hereby aHirm�ha�I am licensxd un�lrr�rovisions of Chap�er 9 REG.NUMBER
(commanc�nq wnh Seclion 7000)of Divis�on 9 0{�he 8usinr.ss power Apporo+us 8 Lorge Appliances DISTRIGT NO. / PROCESSED B��/ �,
ond Professions Code,ond my license is in full ierce and eHecr. /�LaL d
Sire 8 Type HP,KW,KVA,or KVAR < � / �
licPnzr Num6ar 433174 u�.cto:s C-1— ��,�,�i„�i. FihAi �
eo���o��o�WATMAN ELECTR�� Over 1�0 10 Incl. DATE -��L o2.� - VpLIDATION Q
OOve.10 to 50 Incl. FINAL
I am eremp�unde.r Sec. Over 50 to 100 Inc. 8Y �--�(,'U_ '/,' uUi
8.8P.C.for ihfs recson Over 100 v�'�"�CI��'�� h
Serv�ces,Swbd.,MCC 8 Panelboo�ds , � Z
Dc!e: 0-2b0 Amp.Under 5W V
Signature 401-1000 Amp.Under 600 V
❑ Over 1000 Amp.or Over 6pp V
Excmp!ien fer Reg.Mr.i�L Eled.
SIhGLE FAMItY Temp-Powr.r Pole 8 App�rlenonccs �
HQ�ME OWiJE2-BU!IDCR CECIARATION Sign with One.Branch Circuil ��Fi G C/ii �
I l�er�by affirm ihot I orn exempt from rhr.Con�rector's License qddilional Sign Bronch Circuils
Law fcr thr follow�n�reeson(Sec��on 7031.5, Business and fi� � � � �2
Prc!essicns CodeJ:
� M,sc.Conduits R Conductors
I,as owner eF Ihe proper�y,will do ihe work and�he ( • • � �7,2:J
shuc�ure is nal inlen�led or oife�ed ier sale(Section Oiher(See Complete Fee Scheduln)_ , ,
F
]OdG,��SI�Y55(1�(�PlOIPSSiOl15 CCCIP,'. • O • , �j��j L
CONSTRl1CTION IENDING AGFNCY ��,Q 3�H��
I hPrphy aflirm that Ihere is a cons�ruction lending agr.ncy for
ehe performence of�he work for which Ihis permit is iss�r.d PERMIT FEE �Sub•To�al)
(Sec.3097,Civ.C.�.
PLAN CHFCKING FEE
lender's Name
PERMIT ISSUING FEE � �
Lender'z Address 1
I cert,iy thot I hove reod�hls o,^.�I�cnt�on end s!ale Ihal the TOTAI FEE
abo�e inFermar;�n is correct.I�grer,to comply wlih oll Counry
nrdinances and 5! . laws reg��la�ing Electricol w�ring,and
hrreby nu�h ize prexen�aiives of ihis Counry�o en�er upnn �
1hr.obov � oned property for i peclion p�rpeses.
� SEE REVERSE FOR E%PIANATORV LANGUAGE
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