HomeMy WebLinkAbout6407AWORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance, or
a certified copy thereof (Sec. 3800, Lab, C.)
Polier'i o8 0- 6 2 4 9#mp ezrion .Indemnity
® Certified copy is hereby furnished.
g Certified copy is filed with the county building inspection
department.
3-17-81
Date ApplicdE1.7_Mc GP_P_ F 1 P_ r -t r i l'
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the work involved
by the peTMit is for one hundred dollars ($100) or less.)
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers' Compensation Laws.
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be
deemed revoked.
LICENSED CONTRACTORS DECLARATION
I hereby affirm that i am licensed under provisions of Chapter
9 (commencing with Section 7000) of Division 3 of the Busi-
ness and Professions. Code, and my license is in full force and
effect.
License Number 153378 Lie. Class C--.10
Contractor Electrical Data 3-17-81
HOME OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code):
1, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is
issued (Sec. 3097, Civ. C.).
Lender's Name
Lender's Ad
I certify that I have read this application and state that the
above information is correct. I agree to comply with all County
ordinances and State laws regulating Electrical wiring, and
hereby authorize representatives of this County to enter upon
the above-mentioned prSperty for inspection purposes.
3-�7-87
Signa#fie of Per tiintee Data
CE $osC; (2-81), APPLICATION
COUNTY OF LOS ANGELES
FOR
ELECTRICALPERMIT
s
BUILDING AND SAFETY ,_..
FOR APPLICANT TO FILL IN
JOB !,o -t 34
ADDRESS
" 1621S. eSunbluff Dr.
New Residential Bldgs. &Pools
1 & 2-Family,Sq. Ft. 2039
Multi -family Sq. Ft.
Residential Swimming Pools
EACH
NO.
FEE
$
—
S 51.
_
LOCALITY
—
NEAREST
CROSS ST 124 3115
1—Ai y
Outlets: Rec. .Light 1— Sw.
First 20
Total No. Additional
Lighting Fixtures First 20
Total No.Additional
�`
Fixed Appliances Not Over I HP
Range_ Heater_ D.W.
Oven _ Dryer _ W.M.
Top _ FAU W.H.
Hood _ Fan — Other—
Disp. _ Room Air Cond.—
Power Apparatus & Large Appliances
Size & Type HP, KW, KVA, or KVA
Up to 1 Incl.
Over 1 to 10 Incl.
Over 10 to 50 Incl.
Over 50 to 100 Inc.
Over 100
Services
0-200 Amp. Under 600 V
201-1000 Amp. Under 600 V
Over. 1000 Amp. or Over 600 V
Temp. Power Pole & Appurtenances
Sign with One Branch Circuit
Additional Sign Branch Circuits
Misc. Conduits & Conductors
Other (See Complete Fee Schedule)—
PERMIT FEE (Sub -Total)
PLAN CHECKING FEE (One -Fourth Permit Fee)
PERMIT ISSUING FEE
TOTAL FEE
FIRM NAME Preoley
2 ® ADDRESS 4600 Campus Drive
CITY iaetirort Beach Tei No. 5
PLAN CHECK
.6(APPLICANT
ADDRESS
CITY Tel No.
72.167
SEE REVERSE FOR EXPLANATORY LANGUAGE
APPLICANTCrr McGee Electric Inc.
ADDRESSP.O. Box 2886
CITY Pomona Tel No.627-0936
LICENSE OR
REG. NUMBER 153378 Class C-10
DISTRICT NO. IPROCESSED BY
FINAL
DATE
p
FINAL
BY
VALIDATION!