HomeMy WebLinkAbout0848A (4) WORKERS'COMPENSATION�DECLARATION �tA�3 �a�e, APPLICATION FOR ELECTRICAL PERMIT �
I hereby offirm Ihol I hnve a cerfificate of consent lo self CE�806G
insure,or o cr.rliticote ef Workers'Compensation Insurance, COUNTY OF LOS ANGELES T3'g BUILOING AND SAFETY
oi o certified copy�he.reof(Src.3&00,Lnb.C.)
O�y�61JB1010Compony I�1 zNS BROKER iOR AYPIICAM f0 FILL IN �ce
Ceri�f�=d co,y is Fr.reby f�rnished. New Resideniiol Bldgs.8 Pools EACIi NO. FEE ACDRC$
�Certified copy is filed wiih ihe couniy buildin9 inspet• �8 Y�family,Sq.Ft. E = 5 LOCAIITY DIAb10ND BAR
fion dr.pnrlm�nt. Mulfi•family$q.Ft. NEARESi
`� DIAMOND BAR & GRAND AVE
Dote ��pplica�AJATMAN F.T.R!'TRTr
Resideniial Swimming Poolz UwvER OR
fIRM NAME
CERTIFICAT OF EXEMVTION FROM WORKERS' Ouflels:Rec Li ht_Sw. ��'���
� 9 / ADDRE55 4600 C}��US DRIVE
COMPENSATION INSURANCE Firsl 20 �b
(Thls�xtio�need nol ba completed It the work invoirad by Totol No.� Addi�ionol CITY ;�EWPORT BEACH rei.No.540-0500
ths permif is For one h�ndrad dollon(5100)or lo�t.) PLAN CHECK
I te��iiy thot in the perferrnance ol ihe work(er which ihis A�PIICl,YT
permit is issued,I shall nc�employ any persen in ony monner
so os b 6ecor+e wbjed to�he Wo�kers'Compensaiion lows. lighting FiaWres Firs�20 � ADDRESS
Add���onol
Toial No.� CITY Tel.No.
Dote Apnlicanr Fixed Appliances Noi Over 1 HP f+tqMiT
NOTICE TO APPL!CANT: If, ofle.r moking this Certilico!e of �PPIiCANT WATMAN ELECTRIC INC
E.emption, you StiOUI� I;PCCmp subject io thr Workers' Range_Hea�er_D.W._
��....�p,,._r.�.,� .. �(�tiP��ti�.�..�e,y���..�,��+f�.d,. Oven _Oryer —W.M._ ADDRESS 20921 AVENIDA A-�"1-�p�T+A
� wiih comply w�h��s�ch�prov�sions or ihis permil sholl 6e Top _FAU —W.H.—
deemed re�oked. Hood _Fan _O'her_ CITY EL TORO CATai.No.859-8108
IICENSED CONTRACTCRS DECLARATION L'CkNSEOR �lO
I hprpby nHirm Ih�t I em liCensed under provisions oF Chnp7er 9 D�sp. _Room Air Co�d. — REG.NUMBER4331'7 4 Clps�
(cemmencing wi�h$e:�ion 7000)of Division 3 of ihr.Business power Appara�us&Lorge Appliances DISTR!CT NO. PROCES I}�Y y
ond Profess�ons Code,and my license is in(ull iorce and effecl. �� �� 6.
S�ze 8 Type HP,KW,KVA,or KVAR L��� O
license Number 433174 Lrc.Class C-10 UP to I Ind. FINAL V
Over t to 101nc1. DATE L� � jJi! VALIDATION Q
Contrnc�or�T�N ELECTR�� Over10to501nc1. 7
❑ FINAL V
I ar�eaempl under Sec Over 50 l0 100 Int. 6Y W
����^'=l N
B.BP.C.for Ihis rcasan Ovcr 100 ► Z
p'�. SPrvicr.s,Swbd.,MCC 8 Panetboards
0-Z00 Amp.Under 600 V
Signoture 4UI•1000 Amp.Under 600 V
❑ Over 1000 Amp.o�Over 600 V �
Exemp�ion(o�Rny.Ma�nl.El�ct. :='O�LI,F}�i
SINGIE FAMILY Txmp.Power Polc 8 App�r�ennnces ��v � � � �
HO.ME O:"!"JER-BUIIDER CECLA44TION Sign wi!h One Bronch Circu�� ' �
I hereby nifi�m ihot I ar�exempt from thr.Canhoc�or's license Addiriortal$ign 9ronch Circuits i a e]Q ^9
law fer�hc followinq rrnson(SeU�on 7031.5,B�s�ness and "
Professicns Code):
� M�sc.Condu��s 8 Conduciors • • •7 C."�'�'
I,os owner of ihe preperty,w�ll do the work and�he
siru;!�re is not iniended or offared fer soln (Section Other(See Complete Fee Schrdule.)_ , Q �.Q J—�5 tl
7044,B�siness o�d Professions Code).
CONSTRl1CTION LENDING AGENCY
I hereby aflirm Ihat Ihere is a censtruclion lending ogenty for
Ihe per(ormonce of the work(or which�his permil is issuad PERMIT FEE (5�6-Totol) �
(Sec.3097,Civ.C.).
PIAN CNECKING FEE
lender's Name
PERMIT ISSUING FEE D
lender's Address
I ce.riify iha�1 have rond�his applicaiion and s�nte that the TOTAL FEE �C��j
above informotion is torrecl.1 a;ree to comply wi�h oll Counry
ord�n�nces and S� e lows rr�ulnring Elec�rical wiring,ond
hP�Phy pV' e�,resentatives ci�his Coanty�o enier upon
the o m r� ioned p�oper+ti(�pec��on p�rposes.
�L SEE REVERSE FOR EXPIANATORY LANGUAGE
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