HomeMy WebLinkAbout3333 BREA CANYON RD (17)WORKERS'COMPENSATION DECLARATION 76qe63 APPLICATION FOR ELECTRICAL• PGRMIT CE$O6G 12-801
hereby affirm that I have a certificste of consent to self COUNTY OF LOS ANOELES BUILDING ANO SAFETY
insure, or a certificate of Worken' Compeasetion Insurance, ar '
a certified copy thereof (Sec. 3800, Lab. C.) ..a
Noi;Y No. 938449 ReTiublic indemnity FOR APPLICANT TO FILL IN g 3333CompanyEACHNO. FEE ADORESS
IVew Residential Bldgs. & Pools
CerNfied copy is hereby furnished. 1& 2Family Sq Ft $ –" E LOCALI7V Diamond Bar
Certified copy is filed w1'th the county buildinQ inspection
Multi-femily Sq. Ft.
depanment. Btl 1dCL POWC! Zt1C. Residential Swimming Pools
Date 11 8 8Z ppplicent Outlets: Rec._Light Sw._ irst 20
CERT[fICATE OF EXEMPTION FROM WORKEAS' Total No. Atlditional
COMPENSATION INSURANCE •
Cfhis aection need nol be completed if the work involved
Lighting Fixtures First 20bythepermitisforonehundreddoUars (Sl00) or less.) Additional
I certif that in the
Totel No.
y performance ot the work for whith this Fixed ApAliantes Not Over 1 HP
Dermit is issued, ( shall not employ eny person In any manner
So as to become subject to the Workers' Compansation Laws. Range_ Heater_D.W. _
Dete Applicant
NOTICE TO APPLICANT: if, after making this Certificate oC
Exemption, you should become subje[t to the Workeri
Campensetion provisions of the Lebor Code, you must forth-
wi[h comply with such provisions or this permit shall be
deemed revoked.
LICENSED CONTRACTORS DEC4ARATION
1 hereby affirm that I am licensed under provisiona o4 Chapter
9(commenefng with Section 7000) of Division 3 of the Busi-
ness and F'rofessions.Code, and my license is in full force and
effect.
License Num6er [c. Class C 10
Contractor pAple ,11 $..$2
HOME O\VNER•HUILDER DECLARATION
I hereby aff'vm that I am exempt from the Con[ractor's
License Law fvr the tollowing reawn (Section 7031,5. Buei•
ness and Profasions Code):
I, as owner of the property, will do the work und the
structure is not intended or oftered for sele (Section
7044, Business and Professions Code).
CONSTRUCTION LENDING A(3T•.NCY
1 hereby affirm ihat there is a construc ion lending agency
for he performance of [he work for which this permit is
issued (Sec. 3097, Cix C.).
Lender's Name
ender's Address
ertity thet I have read this application and stafe that he
ve infotmation Is correct. 1 agree m comply with all County
inances and Sfate laws regulating Etectricai widng, and
by nuthorize representatives af this County to enter upon
bove-me ione property for inspection purposes.
j ,, 11-8-82
ature oC rmittee Date
Oven _ Oryer _ W.M. _
Top _ FAU _ W.H. _
Hood _ Fa _Other_
Disp. _ Room Air Cond._
Power Apperatus & L.arge Appliances
Size & Tyve HP, KW, KVA, or KVAF
Up to 7 Incl.
Over 1 to 10 Incl.
Over 1D to 50 Ind.
Ovef 50 to 100 InC.
Over 100
Services
0 200 Amp. Under 600 V
201•1000 Amp. Under 600 V
Over 1 D00 Amp. or Over 600 V-
Temp. Powe Pole & Appurtenances
Sign with One Braneh Circuit
Addilianal Sign Branch CirCuits
Misc. Conduits & Conducto s
Other ISee Complete Fee Schedule)-
15
PERMIT FEE - (Sub-Totaq
PLAN CHECKING FEE IOne•Four2h Permit FeeS
PERMIT ISSUING FEE SO
TOTALFEE
SEE'REVERSE FOR EXPLANqTORY LANGUpCE
Fi'ae,i Nn;nne ' Bodeffer Investmenta
MA14
AOOFESS
CITY Saata Ana CA r.' No. 751-7000 >-
PLAN CHECK a
APPLICAMT V
AODRESS . •
CITY Tet No.
U
avnMcnNrBuilders Power Inc. d
N
ADORESS ,9SO N. Elm $[. z
CITV Orange rai No. 633-9094
LICENSE R.
PEG, NUMBE ( Cint
DISTRICT NO. PqOCE55 BY
O
FINALDATE
a'. 3 VALIDATION ,
FINAL .
ev n ,
454..7A
t . • . •,• 2
1 •25,50 ,
25,50 •
i` 2
454.8A
f • . • ,.' .
e e Q
o.e OOd
I 1.08-82
OLYNER-BUILDLR DLCLARAT101
i hc c6y a[1irm th t I am csempt from thc Con[caclor's
iNSr EC7oti•5 - . .....- ' ' I.irens La} f thc follou ing rcason. ectio r 7031.5. i '-,APPTiQVnLS DA7[ _
IGNATUFt...._ . . . . .
ISr,- . . .. . . , ., . ...
7h:surCcs'a>+d ojes.cion.r Code/: Ahy 'dry ar ro uitp .
7er.te.t CP1:S-t',o E- - - -- - . . . ; ' H l;ic7i reqaires e perntrl m eo/tStn cf, after, impr0•C.
den:nfish, nr repcir anj• stnrcture. Priur to its irtum cc,
t .... .. .. ... UNDEF7 LAE'':'ORY. .: ' . . ' . .. _. - : a.o rcqi ir r tf ppnlic4rtt f r.Suel+ pe7 nif tu file R
FiOUGH COtiDU1T -i ' ;.f ' , ' ' s.++t 1. stJ1C+N: f fltCt,e 1$,.riCerised FtfrStlCllt -70 .l11C
wiRiN .' •`
Y = •;. . -
proirsroias of ihe Con(rcc ori lice sc Law (Cirnptrr 9
con rierr+rtg vrd+ Section 7000J of Un`tsioia',o%Ure
a ', r • . F.u:Yuh 3 . _ ' - . _ . , . . . " ' B ecinesr a+rtl Prafcssiorrs CodeJ or tlrat lie ir cxenrp
r .' . , . . _ .. . . . tLerefrom und the Garit for fhe allcged exemption. Anr
Pov:Eicaui't:CitjtZEo. . . ' .rio!atiu olSec ion7031.Sbyu i)'ePplicantforapenrii!
u7i i7Y co. n'o7iFlFo -' . ' subjects the app7icarn to a ciril pcirafty ojnot mo e tpnnI . , . ... . ,.
fire har.drrd do1(cr} /SSOOJ.: - '
Ff^<Ai . . . -_ 'ic j Wt. 20+'L .. . 1, as oa ncr of [h: propertl' will dn the oork, and
thc stnicturc is not intcnAcd or offcrcd for sale.
NOTCS ' . . . .. , . . . Sec. 7041, Giuirsesr ond Prnjessinns CaJe: T6e Coir-
1 tr . , i i . , • . ... . . trcrror's I,iccfesr to eo s,ror ernlr.ro ari on•rrer of
propert u hn builds or impra es tLe coii, m d who does
f _, '::.':7 .._'..,^. . ' .' -,'. _ . ` .• : ' j . such k ork irinucl% prorided tltat such inrprorements
arr not inter ded nr offe ed fu sale. !J, liowerer, fJ e
breildin; nr intprorernerrt i.r sold roidtin one y ea.of
ctiiiiplelioit. lhe. owv er huilder x i11 hare tHe L irde
of prorii;^ rhr.r pe rtid not build.or iinprove fnr 1he
Parrns^ n(salc.J . ., . . . .
I mn e empt under Sec. ,
F3 cf P.C. for tliis rcason
n,,cc, -
O cncr
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