HomeMy WebLinkAbout3333 BREA CANYON RD (19)WORKER$' COMPENSATION DECLARATION
I hereby affirm that 1 have a cer ifica e of conunt o self
insu e, or o certifimte of Workari Compensotion Insumnce,
or a cer ified copy thereof (Sec. 3800, Lob. C.)
Policy No. Company
Ceriified copy is hereby furnished.
Certifiad copy is filed with Ihe county 6uilding inspet-
li o n d eJp o,tment.
Date 11LL L—Appl icant
i /
CERTIFICATE Of EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
TA s Nion nwd nof b eomplN d ii th work invoir d hy
fh p rmit 1 lor on hundr d dollan (f100) ar I n.J
I certify that in the performonce of the work for which this
permit is iss ed, I shall not employ ony person in any monner
so as to become subject to he Workers' Compensaiion laws.
ate /ppiicam
NOTICE TO APPLICANT: If, afrer making this Ce tifica e of
Exempiion, you should become subject fo the Workers'
Compenwtion provisions of the Labor Code, you must forlh-
with comply wi h such provisions o his permit shall be
deemed revoked.
IICENSED CONTRACTOR$ DECLARAiION
I here6y aHirm Ihat I am licensed under provisions of Chapfer 9
commencing with Section 7000) of Division 3 oF he B siness
o d Professions Code, o d my license is in full force a d effect.
License Num6er Lic. Class
Contractor po e
I am exemp't under Sec.
B.BP.C. for this reason
Date:
Signature
Exampiion for Reg. Maint. Elect.
SINGLE FAMIIY
HOME OWNER•BUILDER DECLARATION
I here6y affirm tha I am exempt from 1he Controctor's License
Law for he following reason (Section 7031.5, Business ond
Professions Code):
I, as owner of Ihe property, w ll do the work ond he
slrutture is not iMandad or offered for wle (Section
70 a, Bvsiness and Professians Code).
CONSTRUCTION LENDING AGENCY
I heieby affirm that ihere is a tonstruttion landing agency ior
the performance oi the work for which Ihis pe mii is issved
Sec. 3097, Civ. C..
Lender's Nome
lender's Address
I cenify thai I have read this opplica ion and siate tha the
above informa ion is torrect. I agree to comply with all County
ordinonces and Srate laws regola ing Ebctriml wiring, ond
hereby aulhorize representotives of Ihis Couniy to enlx upon
the above-mentioned property ior inapec ion p rposes.
Signature of Permittee Dote
76A663 ,a,a, qpp CATION FOR ELECTRICAL PERMIT ,) CE-B06C'
COUNTY OF LOS ANGELES • BUILDING AND SAFETY
FOR APPl1GANi TO fILL W q pp 55 J 3.J B ifLIQ c IY V! F/
New ResideNial Bidgs. & Pools
EnGH tr0. FEE
y
1& 2-FamilY, Sq. Ft. 5 — 5 LOCAIITY D A+a a pIQJQ iAOL--
nn iu-rem tysq. F. — c aossSST. D1Q iHO 17 Af2 QGi[
Residanlia Swimming Pools
Oullets: Rec / M.ighf 3 $w.
13
F"g` s°
Total No. Addiiional
lighfing Fixtur e-s-
7
Firs1 20
Total No._
Additional
Fined Appliances Nof Over 1 HP
Range_ Haoier_D.W. —
Oven _ Dryer _ W.M. _
Top — FAU _ W.H. —
Hood — Fan _ Other_
Disp. _ Room Air Cond. —
Gowe Apparaius 8 Large Appliances
Sixe 8 Type HP, KW, KVA, or KVAR
Up fo 1 Incl.
Over 1 to 10 Ind.
Over 1010 50 Incl.
Over 50 to 100 Inc.
o , o0
Services, Swbd., MCC 8 Panelboards
0- 2W Amp. Unde 600 V
201 - 7000 Amp. Under 600 V
Ovar 1000 Amp. or Over 600 V
Temp. Powar Pole 8 Appurlenances
Sign with One Bronch Circuit
Addiiiona 5 9n &vnch C rcuits
Miu. Conduits 8 Conducfors
Other (See Complele Fee Schedule_
PERMIT FEE (Sub-To1ol)
PIAN CHEGKING FEE 6O°T
PERMIT ISSUING FEE . ,
TOTAL FEE . _
SEE REVERSE FOR EXPLANATORY LANGUAGE
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PIAN CHKK r.
APPLIUNT DDT
ADDRESS { x a.
CITY tiy r fS% /j
PERMITAPPLICANT O6%
ADDRESS
CI7Y
UCENSE OR
REG. NUMBER
DISTRICT NO.
1
Tel. No. _a
ii+r%%«/
Tel. No.
Tel. IVo.
Class. -
PROCESSED BY
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VAtIDATION
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64a50
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OWNER-BUIIDER DECLARATION
APPROVALS DATE SIGNATURE -
TEMP. POWER POIE I hareby affirm that I am exempl from tho Contrac or's
License Law for the fallowing roason (Sec/on 7031.5,
UNDERSIABWORK BusinessandProlesslonsCode):Anycllyortavnfywh ch
ROUGH CONDUIT - req lros o permi! fo construct, ahcr, Improvc, demol/sh.
or repolr any stroelore, prior to !!s lisuance, also re-
WIRING qulresfheopplfcanfforsuehpermittoftleosfgnedsfale-
FIMURES - ment }haf ha ls Ifcensed pursuant fo fhc provlstons of tho
Contradori llcanse !aw (Chaptcr 9 (commencing wl h
POWER AUTHORIZED - Sectlon 7000) o( Divlslon 3 0 fFe Business and Proles-
s7ons Code) or that he Is exempf therelrom and Ihe basls
UTIIITY CO. NOTIFIED - /or !he alleged exemptlon. Any Wolollon ot Section
FINAL P c7 . . 031.5 by any appNcanf for a permlt subfects tho opph- Gnter on `son
conl io o Nv1I ponalfy of not moro ihan Iive hondred
NOTES ' , . dollars (SS00).:
I, as owner of tha properly will do Ihe work, and
the slrudure Is not intandod or offcred for salo.
Sec. 704t, Qusiness and Proles:ons Code: The Controc
lor's ltcensc Law does nof apply to on ownor o/property
wha 6ullds or fmproves IBereon, and who doos such
work hlmsel/ ptovldr.d fhat such Improvemenfs arc not
INendod cr ofierod (or sole. ff, however, fho butlding or
Improvement Is sold wifhln ono yeor oJ complo}ion. thc
ownerv6ullder wlfl have fhe burden of proving ihat he did
no! 6u(fd or improve for 1he purpose ol sole.)
I am exempt under Sec.
B& P.C. for this reason
Date _
Owner