HomeMy WebLinkAbout3333 BREA CANYON RD (23)WC'1RKER5' COMPENSATION ECLARATION 76A663 ,o,e,
qppLICATION FOR ELECTRICAL PERMIT 1 hereby aftirm'hat I have n certiticate ol Consent to self ins re,
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or a c`ertiticate ot Workers' Compensation Insurance, or a certif ed COUNTY OF LOS ANGELES BUILDING AND SAPETY
copy thereof (Sec.38D0,Lab G.1'a
M..;e
cy No. CpmPany FOR APPLIChNT TO FILL IN JO[7
Cedified copy is herehy furnished. ' New Residential Bldgs. 8 Pools EACH NO. FEE
A oaeSS
Certified copy is Filed wfth the county buildin9 inspecl on 1 8 2-Family, Sq. Ft. 5 — 5 LOCALITY . `
de rt nL ' Multi-family Sq. F[. — NEARES7 f y,,, / y] /
j , j /.y Residential Swimming Pools
CRO55 5T. O{s) (j?-L fY J 1`(- '«t%
Oate ,_,AppliCOnt I„ '/_/
FRMNAME C` 3'IllRV d
CERTIFICATE OF EXEMPTION FROM WORKERS' putlets: Rec MAiL ,y COMPENSATION INSURANCE
Light Sw. qpDRESS SS
CC
CJ '
This section nestl not bs completatl il the work involved by the First 20
permit Is for one hundred dollar (5100) or leu.) Total No. 3 Additional CITY (`,j( -`,. Tel. No. 6
1 certity that in the performanco of ihe work for which this permit
PLAN CHECK
is issued, I shall not employ arry person in any manner so as to
AP M
become subject to he Worhers' Compensation Laws. . Lighting Fixtures Flrst 20 A DRESS r7 2
Total No.
r- Additional
CITY Tel. No '...
Da[e Applicant
Fixed Appliances Not Over 1 HP
NOTICE TO APPLICANT: If, after making this Cer[ificate of PERMI .
Exemption, you should become subject to the Workers' Compensatlon Range_ Heater_ D.W. __ AP 'T W
provisions ot ihe Labor Cotle, you must torihwith comply with such Oven _ Dryer _ W.M. _ AD RESS (
provisions or ihis permit shall be deemed revoked. . Top _ FAU _ W.H. _
qTY Tel. No. LICENSED CONTRAC70RS DECLARATION Hood _ Fan _ Other_
1 hereby aftirm that I am licensed under provisions of Chapler 9 Disp. — Room Air Cond. —
uceNSe oa
aass. IcommencingwithSection7000) ot Division 3 af the 6usiness end AEG. NUMBER
PfOf@53i0n5 COdO, 8f1d my liCense IS in iull FofCB dfld B(fBGf. DISTRICT NO. PqOCESSED BYPowcrApparatus8LargeAppliances
i
7/^ . —I Size & Type HP, KW, KVA, ar KVAR ` "- "'
j Lkense Number L.-N Lia Ciass ' Up to 1 Incl. - FINAL O
7 7 Over t to 10 1ncl. DATE ^ 7G (K
Contractor ii i Date I- d O l. VALIOATON .
Over 10 to 50 1nd.
FINAL
I am exempt under Sec. Over 50 to 100 Inc. By - - W
BAP.C. for this reason
Over 700
Services, Swbd., MCC 8 Panelboards , Z
Date: 0- 200 Amp. Under 600 V
Signature 201 - 1000 Amp. Llnder 600 V
Over 1000 Amp. or Over 600 V
Exemption for Reg. Maint Elect.
SINGLE FAMILY Temp. Power Pole 8 Appurtenances ' ' 5 3' 7{{
HOME OWNER-BUILOER DECLARATION Sign with One Branch Cimuit •...• 2IherebyaffirmIhatIamexemptfrom he Contractor's License Law . qdditional Sign Branch Circuitstorthefonowingreason (Section 7031.5, Business and Professions
j code): I•• 3 Z 2 5
Misa Conduits & Conduclors - - x
I, as owner of the property, wiil do the work and the strUCture
p her See Com tete Fee Schedule ••
J 7. 2
is not intended or offerN far sale (Section 7044, Business _ ( P 1—
antl Professions Code). O . O b" 8 8
CONSTFiUCTION LENDING AGENCY
I here6y affirm that there is a construction lenrJing agency for ihe
performance of ihe work for which this permit i5 i55ued (SeC. 3097, pERMR FEE (SuC-Ta[aq (P - Civ. C.1.
PLAN CHECKING FEE - -
LendePs Name
PERMIT ISSWNG FEE f p r1 ..
Lender's Addres •
I certify that e r d this application and state that ihe abcvo TOTAL FEE . 7
information' c rre . a e o comply with all County ordinances
a tat a f ecirical wiring, antl hereby auihorize ._ _ . .
pre e I ti 5 f) i u y to enter upon thc a ove mentioned .
prop r ri cf n or ses.
SEE REVERSE FOR E%7LANATORY LANGUAGE - .
S' iature of Permittee 0 t
i '. i ..... : . . : . .. . . :. =. , . . , .. .: :' . : . . , . _ . . . . .
APPROVALS -ATE iNS EC70a'S ' - -- _' - . OWNER-BUILDER DECLARATION
SIGNATURE " - "
TEb P. POWER pOLE • - _ ' , I here y aftirm that 1 am ezempt from ihe Gontractor's Licensc
law for the followirv re son (Section 7031.5, Business and
UN RSLAB WORK . .. _ .. . _ , - ' ' Prolessions Cotle)r Arry city p eoa ty vfiich requires a permit
ROUGH CONDUIT - - - - - - , to coreWct alter, Nnprove, demdish, a repair any sfructure, pia
o !ts Issuance,also equires !he epplicaM for such perm l to file
YlIRING - 7 1 , a signed statement thaf he is licensed pursumit to the prwisions
FlxTURES - % ol the Crnhactor's icenso Law (Chaptcr 9 (commencing with
t' . Sech'an J000) of Division 3 of tho Bvsiness tind Pro/esskr sfn
POWER Al1THORR[0 - . - - CodeJ a tha he !s exempt the.tlran e+nd the basfs for the
allec etl exemptiw. Any violation oi Seetiorr 703 LS by any
UTILITY CO. NOTIFIED - . - appJicant lor a pennit subjects tRe applica f fo o clvi! penalty .
FINAL .' -- ' . . 71 C1' Oit FYOl1t ot rmt more Nan tive hwrdred tlonvs (5500): '
NarEs ,
I, as owner ot Ihe properly will do the viork, and the ,
s:ructure is not inlendetl or oi(eretl for.sale. . ._ .. _ . ,
SeC. 7044, Business and Professiotts Code: , 7he Contractoi S
License Low tlocs irot apply fo en o me -o! property who bullds
a improves fhemon, and who tloes such work himsell'prwided
that such Improvements ale not int^ndeil oi olfcved lor saM.'l/,
havcvc{ fhe building a improvement is sold wiNin rne yem ol
complelion, Ihe amer•Wilder will ha fhc burden of pro n.'nc Ihat
he did not build or lmproJe la fhe purposc'of sale.l .
I am.exempi under Sec. , '
B& P.C. for this reason
Date
Ovmer .,
I , ,