HomeMy WebLinkAbout0838A (4) WORKERS'COMPENSATIONDECLARATION 76A667 �o�a� APPLICATION FOR ELECTRICAL PERMIT �
I hr.reby c!firm ihat I hnve a ceriili;o+e of consent io self �E"�
insure,or o ceriificn�e oF Workers'Cempensotion�nsu�a�ce, COUNTY OF LOS ANGELES �"� BUILDING AND SAFETY
or.a crrtifi�d copy�herraf(Sec.3800,Lob.C.)
^cy NoZfi1�TR1(11Almpany IRM ZNS RR(1KF.g FOR AVPLIC0.NT 70 fILL IN �oe !l�
LJ �PrNfi�d cepy is hereby furnished. New Resideniial Bldgs.8 Pools EACH NO. FEE AC��E55 OG!
�}{Cer��fied copy is f�led wiih ihe county build�ng inspec- 1 8 2-Family,Sq.Ft. E = E LOCAIITY DIAMOND BAR
�<+C G ��EP4EST
�ion dr.pa��men. Multi-family Sq.Ft. � CROSS ST. DIAMOND BAR & GRAND AV
Datr. Apclican� WATMAN ELECTRI Rasiden�ial Swimming Pools OWNER OR
Crfb'� F;4M NANE PRESLEY OF SO CALIF
CERTIFIC TE OF EXEMPTION FROM WORKERS' Ouile�s:Rec�Light,LSw.� MA'L
COMPENSATION INSURANCE � Q ACD4E55
Thl��aclion n��d no1 bs com I�f�d if 1h�work Inrolv�d b F�rsr 20
� P Y To�al No. Addi+ionol CITY NEWPORT BEACH Tel.No. 540-050
ths permif ia for ona hundrsd dollan(f100)er laa�.)
I ce�r�f ihar�n ihr. P�fC�mOnCP of the work for which ihis . t'�AN Ct+eCK
Y P. PP?!ICANT
permil is issued,I shall not emoloy ony person in ony manner
so os�o betome subjecl fo the Workers'Compensotion Laws. ��9ti���9 Fi.lures Firsl 20 ADDRESS
To�ol No._� Addiiional
CITY Tel.No.
Da�e Applicanf Fixed Appl�onces Not Over 1 HP �QuiT
NOTICE TO APPLICANT: If, oitPr m�king this Ce��ificole of APPIICANTWATMAN ELECTRIC INC
Ezemptinn, you should become subjeci to the Wo�kers' Range_Heaier_D.W._
Compenso�ion pro�isions o(the lobor Code,you musf forlh- Oven _Dryer _W.M.— ADDRE55 ZO9Z1. AVENIDA ����
w�th camply with such p�ovisions cr th�s permlt sholl be Top —FAU _W.H.—
deemed revoked. Hood _Fan _0'her_ CITY EL TORO (,'j�Tel,e6�9-8108
LICENSED CONTRACTORS DECIARATION uCENSE OR
I hereby aPfirm ihat I am licensed under provis�ons of Chopter 9 D�sp. _Raem A�r Cend. — eEG.NUh�eER 4 3 3174 Class. C—�.�
(cor�mencing with Secfon 7000)of Di�ision 3 of the Business DISTRICT NO. PROCESSED BY
nnd Professions Code,and my license is in iull force and eHeci. Power Apporatus 8 targe Appl�onces !-
Size 8 Type HF,KW,KVA,or KVAR � Q, 0
License Number d331�4 lic.Clos���1 Fl,yq� V
Up to 1 Incl.
WATMAN ELECTR�� Ove�1 to 10 Incl. DATE � a �7� yq��DATION �
Controc�o� Over 10 io 50 Incl. �
❑ FINAL
I om exempt under Sec. Over 50 to 100 Inc. BY W
B.BP.C.1ar�hls reasnn Over 100 '�v �t��'� v61
Servicas,Swbd.,MCC&Panelboo�ds ► Z
�°�p' 0-�00 Amp.Under 600 V
Sign�hnc 201-1000 Amp.Under 600 V
❑ Over 1000 Amp.or Ove�600 V
E.empiion(or Reg.Maini.EIcU.
5!":GIE fl1.M.ILY Temo.Power Pole 8 Appurlenonces
HCME OWNE4-Bl11lDER DFCLARATION Slgn wlth Onr.Erench G�cu��
I h�r�yy nflirm�ho�I om esempt frem��+�Con�•n:�er's L�cense q��,�;onol Si�n Branch Grcu�ts ��E�.Q�i
Law for ihe(ollow�nq rooson(Sec��on 7031.5,Buvness and — .
Professions Code): rj. � . . ,�
❑ I,as owner of 1ho praperly,will do Ihe work ond Ihe Misc.Condui�s 8 Conductors
s�ructure. is no�in�ended cr of(ered for sa�e(Sec�ion Oiher(See Comple�e Fee Schedule)_ ► � • "V�1 F1 6
70d4,8usiness and Professions Code}. �
• > >GE35;
CONSTRUCTION IENDING AGENCY
I herr.6y r.f(irm that there is a consiruciion lerding agency for 0 1,0 3'$4
fhr,performa�ce of ihe wo�k for which�h�s pe�mii�s�ss�ed PERMIT FEE (Sub•Ta�al)
(Sec.9097,Civ.C.).
PLAN CHECKING FEE
ln.nder's Nnme
PERMIT ISSUING FEE /O S!J
Lr.ndcr's Add•ess
I cartify thot I have read�his applica�ion ond s�a'e thal�he TOTAL FEE GG.�Y�
above�nfamaYen is correct.I erre�ro comply wi�h all Coun�y .
ardinancrs and Sta�e Inws requlaiinq Elecirical wirin�,ond
hereby au�h ize r �=s=niaiives of ihis County io enter upon
�hr.ab • �ed p.orcriy f r�ns ci�on purposes.
SEE REVERSE FOR EXPIANATORY LANGUAGE
,-3�y
ignotur f Permi o Dale
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