HomeMy WebLinkAbout1468A (218) _ �h'ORKERS'COtitPEN5AT10NDFCLARATION 76A6fi3 ppp��CATION FOR ELECTRICAL PERMIT - �
CE�806G(2�8D�
1 herehy attirm thai 1 have a certiticate of consent to se�[ COUNTY OF LOS ANGELES ' BUIl01NG AND SAFETY
ineure,or a cestiflcate of Workers'Compensation Insurance,or
a certified copy ihereof(Sec.3800,Lab.C.)
�� 425745 5tate Fund FOR APPLICANT TO FILL IN �pg
� 1'olicy No. Company NeW ReSidential BIdBs.&Po015 EACH NO. FEE AD�RESS �
�Certiffed c�py is hereby furnished. 1&2-Family,Sq.Ft. $ — § LOCALITV D iamond Bar
� Certified copy is�led�vith the count buildin Multi-famiiy Sq.Ft. — NEA esr D iamond Bor B vd, '
y g inspection CRO55 ST
department. Residenti2l Swimming Pools OWNE a Oa
(�, FIRM NAME B°r P.f S Op
Date �-2 G�—�2Applicant�� Outlets:Fiec.�Light Sw._L t�MAIL same
�ir5t ZO 1 —" L�D�RESS
C1iRTIFICATG OG GXEAIPTION FROSIIVORKERS' Total No.� Addi[ional CITY Tel No. �
C0�1PtiNSAT10N WSURANCE PLAN CHECK �'
APPLICANT a
(This section need not be completed if the work involved �
by the permit is for one Lundred dollars (5100) or Icss.) Lighting Fixtures First 20 AooRESS V
Total No.� additional �
I certify that in the performance of the work fnr which this CITY Tel No. O
permit is issued,I shall not empiny any person in any m�nner Fixed Appliances Not Over 1 HP �.,.
so as to become subje[t to the\Vnrkers'Compensafion La��•s. Range_Heater D.W. APPLICANT Avron Electric, �nC, W
� Oven _Dryer_W.A9._ a�octess 11775 Cardinal Circle ua.i
Uate Applitant Top _FAU _W.H._ _ Z
Nood_Fan _Other_ Ci7YG41' en rove 7el No.
NOTiCF TO APPLICANT:If,af[er making fhis Certificate nf Disp. _Room Air Cond._ LICENSE OR
F.:emption, you shovid become subject to the Workers' REG.NUMBER 416010 Claee C��
Compensation provisions of ihe Labor Code,you must forth- power Apparatus&Large Appliances OIS7RICT NO. PROCES �BV
�vith comply with such provisions or this permit shall be
deemed rexoked. Size&Type HP,KW,KVA,ar KVAR \O
Up to 1 Incl. FINAL
Over 1 to 10 Incl. oATE Z—S � 5 VALIDATION
L[CENSED CONTRACTORS DECLARATfON Over 10 ro 50 Inel. �
1 hereby affirm that 1 am licensrd under pmvisionx nP Chnpter Over 50[0 100 Ine, FINAL
BV
9 (commencing with Srction 7000)of Division 3 ot the Husi- pVef 100 �
ness and Protes5ions Code,and my license is in full torce and
effecL . Services
License Number 416010 Lic.Class C�� 0-200 Amp.Under 600 V
�,4vron Electric 2/4/S2 201-1000 Amp.Under 600 V
Contncto Date Over 1000 Amp,or Over 600 V
I�iOS1F.OtYNFR-BUILDI:R DLCLARA7fON Temp.Power Pole&Appurtenances �
Siqn with One Brench Circuit
[ hereby affirm I�mt I am exempt from the Contrector's Additional Sign Brench Circuits
License Law fnr the fnllowing re�son (Section 703L5, Husi- �
nesc and Prnfessiona Cnde):
MisC.Conduits&Conductors
� 1,as owner o(the property,avill do the urork and the Other(See Complete Fee Schedulel—
structure is nat intended or ofkred for saie (Section . �� (���A �
7044,Business and Professians Code).
CONSTRUCTION LENDING AUENCY �,. � � . .2
I hereby af(irm [hat there is a construction lending agency
for the performance uf the work for which this permit is pERM�T FEE (Sub•Total� ,b �,���2�3�
issued(Sec.1097,Civ.C.).
Lender's Name PLAN CHECKING FEE IOne-Fourth Permit Fee) �• e
•25JO�
LendeNs AdJress PERMIT ISSUING FEE
0204�82
1 certify ihat 1 have read this application and state that the TOTAL FEE -
above informatlon Is correcL I agree to complY�v�1h all Coun[y .
ordinances and State 1a��5 regulating Glecirical wiring, and - '
hereby authorire r, resenta' s of Ihis County to enter upon .
th � ov- entio ptope y or inspection purposes.
/ � �Y SEE'RBVERSE POR IiXNLANATORY LANGUAGH
Signature n }'ermittee ll e
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