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WORKERS'COMPENSA710N DECLARATION 76A6E3 �o,e, APPLICATION FOR ELECTRICAL PERMIT �
I hereby a}firm that I have o certificate of consent to self CE'806G
insure,or o cenificote oF Workers'Compensotion Ins��once, COUNTY OP LOS ANGELES BUILDING ANO SAFETY
or a cert�fied copy ihereaf(Sec.3800,Lab.C.)
WS��7.�(�162 Compon�remont Ind. FOR A/►UCAM TO FlLL IN �oe
� Cerlified co ADORESS 23769 Sunset Crossin Rd. �
py is hereby furnished. New Residential Bldgs.8 Pools EACH NO. FEE
� Ceri�ltod copy is f�led with the covn�y building inspec- �g 2-Family,Sq.Ft. E — S LOCAIITY Diamond Bar
tion depariment. Mulli-fomily Sq.Ft. — NFAREST
Daie 2�6I84 � Res�denfiol Swimming Pools CROSSST.
Applitanf OWNER OR
FIRM NAME
CERTIFICATE OF EXEMPTION FROM W KERS' Outlets:Rec_Llight_Sw._ �`��
COMVENSATION INSURANCE .4DD4E55 23769 Sunset Canyon Rd.
(Thb�Mion nNd not b��empl�ted 11 fh�work involr�d 6y F�rst 20
the p�rmil i�for one hundrad dollars(SI00)or In�.)
Total No. Additional aTv Diamond Bar Tel.No. $98—�
I cerlify tFiat in the per(ormonce of Ihe work for whlch this PLAN CHECK
ermil is issued,I sholl nof em lo on APGLICAN7
P P Y Y Person in any manner
so os io become sobjact to the Workers'Compensation Laws. lighiing Fixtures Firzt 20 ADDRESS
Toral No. Addi+ional
Date Applicant CITY Tel.No.
NOTICE TO APPLICANT: If, ufter moking ihis Cer�ificate of Fized Applionces No1 Over 1 HP PERMiT
Exemplion, yo� should become subject to the Worke�s' Range_Hea�er_D.W._ Aa'ucqNi mited
Compensotion provisions oi the Lo6or Code,yo�mvs�forth• O�en _Dryer _W.M._ ADDRE55 $2 $. Magnolia BLVd
with comply with such provizions or this permit shalt be
deemed revokr,d. Top _FAU —W.H._ CITY BUT an Tel.No.
LICENSED CONTRACTORS DECLARATION Hood _fan _Othar_
Dis _Room Air Cond. — i�CENSE OA
I hereby aNirm rhet I am licensed under provisions of Chopfer 9 P' �G.NUMBER C�ass.
(mmme�cing with$eclion 7000)of Division 9 Of Ihe Business power Apporotus 8 large Appliances DISTRICT NO. PROCESSE BY
and Professions Code,ond my license is in fuli Force and eftect. Y
393565 SC44 Size 8 Type HP,KW,KVA,or KVAR /li' 0
License Numher Lic.qoss Up 10 1 Ind. FINAL V
DATE� pc
Co�i�ouor Solar Unlimited pa�� 2/6/84 Over 1�o IO lncl. �_�_, �rj VALIDATION �
OOvar 10�0 50 Incl. FINA�–� �" ,
I am ezemp�onder Sec. Over 50 to 100 Inc. BY � � W
8.8P.C.ior this reoson . �vef�� �1� H
Services,Sw6d.,MCC 8 Panelboards ► Z
Date: 0-200 Amp.Under 60p V
Signature 201-1000 Amp.Under 600 V
❑ " Over 1000 Amp,or Ovar 500 V
Exemplion ior Reg.MainL Elett.
SINGLE FAMIIY Temp.Power Pole 8 Appurtenances
HCME O`7JP:ER-BURCER CECLARATICN Sign with One Bronth Circuil
I hereby oHirm thot I am exempt 6om the Controctor's License q�ilional Si �s,e„�h c����« �1 4 5 6 A
Law tor the following reason�Section 7031.5,Business and 9 � �
Professions Codr.): ' �. . . • .2
i ❑ I,os owne.r of the o rt,wilt do ihe wo�k ond the ' M,st.Condvirs&Conduc�ors
P� � Y O�he� See Com lete Fee Schedule_ � • • , �.2 5
structure is not intended or offered for sale(SeUion � ( P ) ►
7044,Business ond Professions Code). i ,
CONSTRUCTION tENDING AGENCY ; °,• • � ��G�J cSa
I hereby offirm thot Ihere is a tonslruclion lending agency for i
the periormonce of ihe work for which rhis permii is issued � pERMIT FEE (Sub-To�al) 5 0 2 C 9-8 4
(Sec.3097,Civ.C.). -- :
� PLAN CHECKING FEE
lender's Nome
PERMIT ISSUING FEE
Lender'S Address - '
I tertify tha�1 have read�his applimtion and state Ihat Ihe � TOTAL FEE ].]..2
above informofion is conect I agree ro comply with all County _
ordinances ond Stote laws regulaling Eleclrical wi�ing,and �
here6y oulhoiize represen�alives oi this Counly to en�er upon . �
the above.meniioned property for i�specrion purposes. SEE REVERSE FOR EXPIANATORY LANGUAGE
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