HomeMy WebLinkAbout0831 WORKERS'COMPENSATIONDECIARAT10N 7hA667 ,o�e, APPLICATION FOR ELECTRICAL PERMIT �
I hereby a{(irm Ih�l I hove o ceriifi[a�c o�consenl b self CF�B06C'
ins�rc,or o cc��ifica'n oi Workers'Compe�sn�ion t�suronce, COUNTY OF LOS ANGELES .E y BUILDING AND SAPETV
or p c=rtifir.d copy thereof(Sec.3800,lab.C.)
O�y No 761JB10�(�,���Y IRN INS BROKER FON APPIIUNf i0 Flll IN ��s /J . Q
Certi{iqd Copy is here.by Fumished. Nr.w Rnsidanlial Bldgs.8 Pools FACH NO. FEE A�OR[S$ J(a �/ /
�Cerli�ied co�y is(iled with the counly building inspec• �8 2-Fomily,Sq.FI. s — 5 LOCALITY DIAMOND BAR
rion depa�rme�. Mvlri-fam�ly Sq.Fi.�//� — ( ��EAREST
i Rr.sidr.ntial Swimming Pools UWNFR O4
Do�e ' " APplicnn�WAT.MAN ELE GTRIC � F,RM n,w�cPRESLEY OF SO CALIF
r+`rr°� M-4'� 4600 CAMPUS DRIVE
CERTIFICATE OF E%EMPTION FROM WORKERS' Ouilets:Rec�Lighl�Sw.�
COMPENSATION INSURANCE 3 A[7�aE55
/ Firsl 40
(Thli��clion na�d nof b�complN�d lf tho wo�k Inwlrad by Tolal No. ` Additional CITY NEWPORT BEACH Tel.No.$4 O—O$O O
the permif i�ior on�hundrad dollan(SI00)or le�s.) P�AN CHF.CK
I cerfify�hor in ihr,perfo�monce of the work for whfch ihis AFaIICAn:T
pe�rn�i�s Issued,I shall not employ nny person in any manner
so os�o become subje:t to ihe Workers'Compenv,�tion Laws. Li9hring Ficrures First 70 ADDRE55
Total No. / Addii�onal CITY Tel.No.
Do'e APP��co�� Fi.ed Applioncxs Nof O�er 1 HP �K.w��
NOTICE TO APPL!CANT: If, aiter moking this Cerii(ica�e of aPPi,c��jpTATMAN ELECTRIC IN�.'
E.emption, you should 6ecome 5�6jec1 10 �he Workers' Ra�ge_Healer_D.W.—
.. . :���.e!..y�•r:��, _ _S�{...�ti_ Ovnn _�ryP _W.M._ ADDRESS O AVENIDA ANSAPOLA
wiih�cemply^with�such�provisions ar Ihis permil shall be Top _FAU' —W.H.— CITY EL TORO �.'A Te�.nio.8$J—HZOH
I deemed rr.vo4ed. Hood —Fan _Other_
UCENSCD CONTRACTORS DECLARATION uCC:�SE OR
I he•eby oHirm ttio�I am licensr.d un�r provisions of Chap�er 9 Disp. _Room Air Cond. — REG.NUMBER Clos.—
� (commencing with Section 7000)of Division 9 0l�he Business pa�„yr Apparo�us 8 Lorge Appliances DISTRICT NO. PROCESSED BY �,
I anJ Pro!r.ssions Code,ond my I�cense is�n full Force ond effect. /Q � 6.
Sire 8 Type HP,KW,KVA,or KVAR �� O
433174 C-10 v
L�cense Numbor Lic.Closs Up to 1 Incl. FINAL
NIATNIAN ELECTI�� Over 1 to 101nc1. DATE �� �/a7i1 yp��DATION Q .
-� F
Contr�ctor Over 10 to 50 Incl.
❑ FINAL V
I am exempt under Set. Ovar 50 fo 100 Inc. BY �
�vi1�+02t d
� Over 100 'A
8.8P.C.fo�+h�s recson ► Z
Dare: Services,Swbd.,MCC 8 Panelhoards
0-200 Amp.Under 600 V
S�gn�iure 401-lOW Amp.Under 600 V �
❑ Over 1000 Amp.or Over 600 V , �
EKemp�icn for Reg.fAcint.Elecl. �n
SIM1GtE FAMILY Temp.Power Pole 8 Appurlenances V��� ,
H0.1AE O'.4'tiER�BU�LCER DECLARATION $�9��„�th One Brnnch Cirtuit ypt
I hereby a(hrm ihoi I am r..empi frem ihe Comrocior's License Addliional Sign Bionch Cirtuiis ��'•C"'���`''
Law for Ihe following�eason(Seclion 7031.5,Business and
Prolessions Code): �
❑ I,as owner o!thr.p•eper�y,will do�he work and rhr. Misc.Condui�s&Conductors � � .
shucrure is not iniended or offered fo�so�e(Sec��on �'her(See Compleie Fee Schedule)_ ► �O���
704A,Rusin=ss and P.o�essicns Codr.).
CONSTRUCTION LENDING AGENCY \1���-J+'
I hereby affirm thai there is o cons'ruction lending agency for ��f
+Fe per(o�monce oi ih�work 1er which this permi�is issued PERMIT FEE � (Sub•Tatol)
�Sec.3097,Civ.C.�.
PIAN CHEfKING FEE �
lendor's hame
PERMIT ISSUING FE[ ,
Lendcr's Address
I cer�ify that I havr.rend this opplicalion ond s�are th�t ihe TOTAL FEE �a, .
nbovn infcrr�otion is corre•.t.I�gre?�o tom�ly wi�h oll Coun�y
erdinanc=s and Si e laws regu�a��ng Eletlrical wiring,nnd
hereby aut epresen�otives of this County io enter upon
Ihe r'tio�ed p�n{�P<<Y�or' specfion purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
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