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WORKERS'COMPENSATIONDECLARATION 76AbA7 ,o�A� APPLICATION FOR ELECTRICAL PERMIT
I here6y ofiirm�hal I have a certifica�e of consenl�o sel( CE�BOEC
i�su�e,ro�a ce�rlico+e ol wo.kr.�s:Compensa�ion�nsuronce, COUNTY OF LOS ANGELES BUILDING AND SAFETY
o�a�ertified c; thereof(Sec.3800,Lnb.C.)
O1 W��111��A Su�erior National
. P❑o�ity No. Com ony FOR APrl1GNT TO�1LL M J06
�C�rillfod copy is hereby furnished. New Residentiol Bldgs.8 Poals EACH ni0. FEC �`�REu 1148 Ranchwood PL.
� Ceriifed cop is f�led with�tie cou y ng fi�sp c- 1 8 2�Fam�ly,Sq.Fr. E _ = IOCALITY Diamond Bar
li w eparl nt. ' / M�Iti�iamily Sq.FI. NEAREST
Residentiol5wimming Paals CROSSST.
Do�e Appl�c � G owNeR«+ Sahara Pools
FIRM NAME
CERTIF pTEOFE% PTIO FROMWORKERS' Ou�le�s:Rec_light_Sw._ �`O'�� �rjQ W. Ciene d
COMPEN TION SURANCE AD�aF g
(Thi��Mion nNd noh b plH�d if Ih�work Invelr�d by Firs1 YO CITY
�h�p�rmif i�ier on�h�ndr�d dollors(SI00)or la�s.) To�ol No. Additionol $dII Dima s Tel.No.
I terlify that in the performonce of fhe work for which this qPRiCANTK
permil is issur.d,I sholl nat employ ony pr.rson in any manner
so as ro become su6jec�ro the Workeri Compensaiion Laws. Lighting Fi.lurPs Firsl 20 ADDRESS
Total No. Addilionnl
Da�e Applicant Tel.No.
NOTICE TO APFLICANT: If, af�er makin �his Cer�ifica�e of FiRed Appliances Not Over I HP PER�v.rt
9 R�n e_Heoter_D.W._ /PRiCnnInTOYIII A. MartinHt & A/C
Exemption, you s�+ould becomr. subjr.ct lo the Workers' 9 �
Compenso!�on provisions of�he Labor Code,you must forih- Oven _Dryer _W.M.— ADDRE554�}2 W. Boni ta AVe.
wiih comply w'Ih such provis�ons or Ihis perm�� sholl be. '(op —FAU _W.ti.—
deemed re�oked. ��TSdil Dimas r��.N�599-2901
LICENSED CONTRACTORS DECIARATION Hood _Fon _O!her_
I hereb aHirm�hol I om I��e�sed�nder '' Dis�. _Reor�Air Ccnd. — LiCENSE OR Cios:. (,'2�
y p.o��s�ons of Chopter G r�o.huMe�a 31510 3
�commencing wiih SaUion 7000)of Divis�on 3 of�he Business power A a.n�us 8 Lar e A, I ances D!STRICT NO. PROCE BY y,
and Pro�asslons Code,ond my I�censr.�s�n tull ferce ond effect. � Q �P' p,
Size 8 Type f+.P,KW,KVA,or KV � �Q Q
license Num6er 315103 �i Closs C20 Up in 1 Incl. FINAL V
� ��/ .�.Over 1 to 10 Incl. �ATE � ��/�� VALIDATION �
� Con�roc� �aie�� Over 10 fo 50 IncL FINAL V
❑ 1 ar� .empt under Sec. Over 50 io 100 Inc. BY W
d
Over 100 � N
. P.C.ior rhis reason I , Z
� pa�e, Ser�ices,Swbd.,MCC 8 Panelboards
� 0-200 Amp.Under 5W V
Signature 201-1000 Amp.Under 600 V
. ❑ OwPr 1000 Amp.cr Over 600 V
Erempi�on for Reg.Moint.Elet�.
SINGIE FAMIIY iemp.Power Pole 8 Appu�tenancas �
HOME CWNER-BUIL�ER DECIARATION Si�n with One Bran;h Cfrcuil .
I hereby ollirm�ho�1 am exempl irom Ihr.Conhnclor's License Addiiiv�al Si,�B•��ch C�rc�its '
law for fhr.follnwinq reason(Sec��on 7031.5,Bus�ness onA _r,� � G�� �
Professions Code):
' ❑ I,as owner oi ihe t "II do the wark end the Misc.Conduiis&Conduc�ors '; . . . .a
P�oP`�Y,wi
� struc+ure is net in!ended or eFfered 1or sole(Sec��on ��her(See Complere Fee ScheduleJ— ,
7044,Busiress ard Prefessions Code). � • '� �•5 7 ,
I CONSTRUCTIOV LENDING/�GENCY �+ + ^ � L J v u
, I hereby affirm thot fhere is a construc�ion lending ogency for ,���
the pr.rformoncr.of thr.work for which this permil is issued pERMIT FEE (Sub-Te�al) �C.!_C'a 7
(Sec.3097.Civ.C.).
. PLAN CHECKING FEE . .
Lender's Nome
PER.M.IT ISSUING FEE � �
� lender's Addre.ss t �
� I cenlfy iha�I hove read ihis opplica�ion and s+nle Iha�ihe TOTAL FEE L.
abo�e info�mo��on�s torrec�.I agree�o comply wiih all Caunty
� ordinnntes ond Sto!e lows regulating Electrical wiring,ond
, hereby a orire r presenfo�ives oF�his Counly t enter� an
ihe obo em' nr.d iy!or spection pu oses. SEE REVERSE FOR EXPLANATORY LANGUAGE /
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