HomeMy WebLinkAbout0836A (4) N'ORKERS'CO++�.PENSATIONDECLARATION �6�� �o�e� APPLICATION FOR ELECTRICAL PERMIT �
I hereby nfiirm Ihal I have a cerlificale of consent to self CE-806C
+r+sure,or o corrifica�e oF workeri Compensa�ion Insurance, COUNTY OF l05 ANGELES �� BUILDING AND SAPE7Y
or,n cr.rulied copy 4�e�eot(Sec.3600,Lab.C.)
a�yNo761JB107.�mpany I� INS BROKER ►ORAYPIICAM70FIllIN �oe �
Certified copy is hcreby furnished. New Resideniiol Bldgs.8 Pools EACH NO. FEE �CDaESS
�L�L_Certified tepy is filed wiih ihe county 6uild�ng inspet- 1 8 2�Fomlly,Sq.Ft. E = 5 LOCALITY AMOND Ba�F2 '
X�CX tion dPpar�meni. Multi-family Sq.Ft. tvF,a4ESi
cRosssr. DIAMOND BAR & GRAND AVE
sidential Swimming Pools ONhfk OR
Da�e � — ` Appllcant t�ATMAN F.T.F.C`TRTC �� fIRM N4ME PRESLEY OF SO CALIF
CERTIFICATE OF EXEMPTION FROM WORKER$' Oullels:Rec/LightLSw.� MA��
COMPENSATION INSURANCE � ACDQE55 4600 CAI�SPUS DRIVE
Thi�saNion nead nof ba com I�I�d i/lb�work involv�d F�rst 20
� P �' To!al No.� Addi�ionol CITY 7e1.No.540-0$OO
fha permil is for one hundrad dollon(5100)or Is��.) •
PLAN CHECK
I cr.ni!y rhvt in rhr perfcrmancc of th�wo�k 1or which this Fw+uCnhT
pe�mit is iss�ed.I sh�ll no�employ ony rrrson in ony monner
so as�o becnme subiPct to ihe Werkers'Compensot�on Laws. li9Minq Fi*�ures Firsr 20 ADDRE55
Addi�lonol
To�nl No. CITY Tel.No.
Da�e. Applicnnl Fixed Appliances Nol Ove�1 HP pER�,�i�
NOTICE TO APPLICANT: I!, aBer mok�ng �h�s Ceriif�m+e of A�IICANT WATMAN ELECTRIC INC
E+emp��on, you should FIPCOI`IP su6jxcl to thr. Workers' Ronge_Heo�er_D.W.—
�,....�e,.�,.�����.���.�„��nF ehn�„ti,,.C,,.{,.,yn�!�++i�si I,,.iF.. Oven _�rynr —W.M._ ADDRESS 20921 AVENIDA AMP,POLA
wi!h comply wi�h such provisions or Ihis pe�mil sholl be 7op —FAU _W.H.—
deemed reve4ed. Hood _Fan _Oiher_ CITY EL TORO CA rai.N�59-8108
LICENSED CONTRACTOPS DECLARATION i�C!'•:Se OR
I hereby aHirm Ihol I am licensed under provisions of Chopler 9 D�sp. _Room Air Cond. — REG.NUMBf Closs. _
(commr.ncing wi+h Seciian 7000)of Div�sion 3 oi ihe B�s�ness power Apporotus 8 lorge Applionces DiSTRiCT NO. PROCESSED BY Y
and Professions Code,ond r�y license is in f�ll force ond eNecl. �O p,
433174 (,'-1� $ize 8 Type HP,KW,KVA,or KVAR Q
License N�mbnr lic.Closs �P�o�����. FINAL / V
Over 1�a 101nc1. DATE !� ?/�ef VAIIDATION �
Cono-ac+or WATMAN ELECTIb�� �
❑ Over 10 to 50 Incl. FINAL . V
I om exempt under Sec. Over 50 to 100 Inc. I BY � //A�� N
Over 100 ��i ••cLY— " �•
B.BP.C.for ihis reoson Z
p�p_ Services,Swbd.,MCC 8 Poneiboords ►
0-Z00 Amp.Under 600 V �
Siqnahnc 401-1000 Amp.Undar 600 V
❑ Over 1000 Amp,or O�er 600 V
E.nmpnon(or Rrq.Idn�nt.Eicct.
SINGIE FAMI�Y Temp.Power Pote 8 Appurienances
HpNE OW'VER�P,UIICER CECIARATION 5;9�wiih One 8ronch C�rcu�� �G�����
I here6y�Ilirm ihnt 1 am r,xempf(rom�he Contrattor's License qddi'ional$ign Branch Circuits
Low for thr,following rea<,on(Set�ion 7071.5, Business and i:• • • • •2
Profess�ons Code):
❑ I,as owner of ihn property,wiil do the work nnd the M�sc.Condu��s 8 Cnnduc�or: � • •O�i A F
slruclurr is nat If11Pl1fJf(I or offered for sale (Section Other�See Comple�e Frr.S�hedul�)_ ,
7044,Businnss and Proinssions CodeJ. • e e(j F�fj T
CONSTRl1CTION IEhDING AGENCY 0 1.G 3—fi!:
I hereby a�firm iha�ihr.rP is a cons!ructlon lending ogency ior
Ihe performoncr.af the work for which ihls permll is issued PERMIT FEE (5�6-Toinl)
(Src.3097,Civ.C.).
PLAN CHECKING FEE �
Lender's Nome
PERMIT ISSU�NG FEE �
Lender's Add�r.ss �
I cerlify lhot I h�vc read ihis applimtion and sta�r,that the TOTAL FEE
above inFo•motien is corre.cl.I n�re=to comply wiiti ail Co�niy
ordinnnces and Starr. Inws regula��ng E�r,ci�icol wirinq,and '
hereby au� or' ,repres>nt��ivcs r,f ihis Counly to eMe�upon
thr. -m iianed p.cpe�ry(or ir ec��on purposes.
/ p- SEE REVERSE FpR EXPLANATORY LANGUAGE
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