HomeMy WebLinkAbout5941hWORKERS'COMFENSATIONDECLARATION
CS-806G(2-80) APPLICATION FOR ELECTRICAL. PERMIT
I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY
insure,or a celiMp"te of Workers'Compensation Insurance,or
racertifiedcolifthereof(Sec.3800,Lab.C.)
Polley No. ompan
80-6249cy Fremont Indemnity FOR APPLICANT TO FILL IN JOB Lot.28 20867 Missionary Ridg St.
New Residential Bldgs.&Pools EACH NO. FEE ADDRESS
Certified copy is hereby furnished. 1&2-Family,Sq.Ft. 3635 $ — $ 90 LOCALITY TR#310 —ZDiamond Bar
Multi-family Sq.Ft.NhAllhbl
Certified copy is filed with the county building Inspection CROSS ST
department. Residential Swimming Pools OWNER OR M. J. Brock 5 Sons,Ine.
Date p
10-20-8Q
nCa McGee Electric FIRM NAME
piicant Outlets:Rec._Light_Sw._ MAIL 1698 Greenbriar Ln.
First 20 ADDRESS
CERTIFICATE OF EXEMPTION FROM WORKERS'Total No. Additional CITY Brea 92621 Tel No-529-8170 }COMPENSATION INSURANCE PLAN CHECK 6-
This section need not be completed if the work involved
APPLICANT L)
by the permit is for one hundred dollars ($100)or less.) Lighting Fixtures First 20 ADDRESS
Additional
I certify that in the performance of the work for which this
Total No.
CITY Tel No.
Fined Appliances Not Over 1 HP
permit is issued,I shall not employ any person in any manner PERMITrr rr
so as to become subject to the Workers'Compensation Laws. Range_Heater_D.W._ APPLICANT C McGee Electric IIIc. tl
Oven _Dryer_W.M._ ADDRESS P.O. Boa 2886 Z
Date - Applicant - Top _FAU__W.H.._
Hood_Fan _Other_ CITY Pomona 91766 Tel No. 627-0936
NOTICE TO APPLICANT:If,after making this Certificate of Disp. _Room Air Cond.
REG.LICENSEanseRt533 8 C-10Exemption, you shout become subject to the Workers' Class
Compensation provisions of the Labor Code,you must forth- Power Apparatus&Large Appliances DISTRICT NO. PROCESSED BY
with comply with such provisions or this permit shall be Size&Type HP,KW,KVA,or KVAdeemedrevoked.
Up to 1 Incl.
FINAL
Over 1 to 10 Inc. DAT VALIDATIONLICENSEDCONTRACTORSDECLARATIONOver10to50Incl. -
I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc.8Y
9(commencing with Section 7000)of Division 3 of the Busi•Over 100
ness and Professions.Code,and my license Is in full force and
effect. Services -
License Number 153378 Lic,Class C-10 0200 Amp.Under 600 V
201.1000 Amp.Under 600 V.
Contractor El ect-4 rnl Date 10-22-80 Over 1000 Amp.or Over 600 V
HOME OWNER-BUILDER DECLARATION Temp.Power Pole&Appurtenances
I hereby affirm that I am exempt from the Contractor's
Sign with One Branch Circuit
License Law for the following reason (Section 7031.5,Bust- Additional Sign Branch Circuits
ness and Professions Code): 5 9 1,-1 P.Mist.Conduits&Conductors
1, as owner of the property,will do the work and the Other(See Complete Fee Schedule)—
structure is not intended or offered for sale (Section
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY s e O 7 G F
1 hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is PERMIT FEE Sub-Total) 90 88 e .97rS75
issued(Sec.3097,Civ.C.).
Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee) I C 2 B—85 0
Lender's Address PERMIT ISSUING FEE 7 DQ
I certify that I have read this application and state that the TOTAL FEE 97.88
above information is correct.1 agree to comply with all County
ordinances and State laws regulating Electrical wiring, and
hereby authorize representatives of this County to enter upon
the ab o •mention d p Qerty for inspection purposes. SEE'REVERSE FOR EXPLANATORY LANGUAGE
10-22-80
ature of Pe"O.-tee Date
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