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HomeMy WebLinkAbout1014A (5) � ' WUHKtiKS'CpM19PEN5APIONDECL.�IRATION 76q663 APPLICAT141V FOR ELECTRKAL�PERMIT � {� ' CE 8�6G(2-80) I herehy affirm thu� I Yiace a certificatu of ccinsent to�telf C�UNTI�OF L�S AN(�iE�E$ BIJI�DI(11Ci ANp$QFETY � insure,or a certifica[e nt Wurkera'ComPensa[ion lnsurance,or n certified copy the[eof(Sec.JB00,i.ub.('.) P y — _ FOR APPLICANT TO FILL IN �pp t„�� ,�/�,,��`�rp � � Yolicy N<�. ('nm �n' EACH NO. FEE ADORESS � //��/1,$� F)J New Residential Bldgs.&Pools __ r� Cer[ificJ copy is hercby furnisheA. }g(2-Frmily,Sq.Ft. $ — � �OCALITY f��i�;��, .�4�� � Multi-family Sq.Ft.____ NEAResT """--— Certified r.upy is filed with the coimty building inspec[ion CROSS ST department. Residential Swimming Pools oWNER oR �}'� C¢� i � �r � ? FIRM NAME �`(� C�Yi,�. Uata Appiicani . Outlets.Rec.!Light �7':Sw.j� Mql L �y�� ' F'ifs�20 />ODRESS��T+'!� CER"CII'lCA7'H Of F,XEMPTION FROD7 WGRKIiRS' Toial No[� Addivanal � _ __ � CITY �(,�-��ai No.+✓� � COMPENSA'LIUit''INSURANCb: . , PLAN CHECK �� 1' r j/ APPLICANT ___' O (This section need not be completed if the wurk involved t � 6y the permit is for one hundied doiiaxs 5100 or le5s. ` Lighting Fixtu�res First 20 / � � ) ) � � / f —ADDRESS — . �".._—"'_✓ � . Total No.!_�_ A��'tionat � I certify fhat in t}�e p�rform;ance of Ihe work Cor�v�hich this CITV _.T-et"No�� p porsvn in:my manner � Fixed Appliances Not Over i HP Q pennit is issued,t shul!nnt em Ioy any PERMIT � � s��ic tn I�ecnme suhject to Iha WurAers'C'ompensntion Lsu�s. � Ranqe�Heater_D.W._ qPpLICANT _._ _ � . Oven ...._DrV�r_W.M._ y ADORESS,.- j Date AVplicant_ .'�� Top _FAU _W.H.__ ..==_—.- ._ _.._ .� Hood_Fan .._Other_..__ ci7�'"'"'� Tei No. � NOTICE TO APPLIG'+�7�: If,afrr making chis Certificatc of DiSp. ,_RoOm Air COnd.` LICENSE�OR - --� � t:xemptiun, y�ou shoutd become xubjed to thc 6Vorkers� � f�4EG.NUM6ER Class f Compensation provision[;i>f tf�e Labor Code,you�nuet�'o[th- !�,�ppWer ApparaNs&LargB Appliances ' DISTFiICT NO. PRQ ESSED 6V iwi[h cumply �aith such provisions or this permit shall be Si�e&T r � � deemsd reroked. VP-HP,KW,KVA.or KVAR 7 _ Un to 1 Incl. i � `� �7-- �:i��'Y'1.1"� T. ��,� ___"_ FINAL _—' _'___ Over 1 to 10 incl. LSCENSED CUN'1'RACTORS i)ECLARATION ` Over 10 to 50 Inci. DATE f" /9 �,� VACIDATION + i (herebt•af'firm 4hat 1 am licensed under procisions of Chapter � �---- Over 50 t0 700 Inc. . FINAL � 9 (commcncing with Srction 7000)of Uivisinn 1��f t6e Busi- � BY _ "� ' � Ovcr 100 - � 2���,�,�_ ness and Prnfr.ssions Cnde,and my lice�ise is in full foree and " �� cffect. ' � ��' Services �I.icenseNumber__ Lic.Clasa.______ 0-200 Amp.Under 600 V � 207-?000 Amp.Un:ler 600 V Can[rHctor ._____ Dnte_..___________ � Over 1000 Amp.or Over 600 V _ � HOASIi OIYNEn.gU1LDER lll�Ci,ARA'ITCiN �a remF��o�^!er Pole&Appurtc�ances � F�Siyr.with One Branch Circult � � I hereby affirm thuY 1 xm exempt fKom lhe Contr,ryctur'E � — Lieanse Liiw Por the fullow•ing reason (Sectiun 7031.5, Rusi- p�A��itionai Sign BranCh Circuits ness and Professions Cnde): : Misc.Conduits&Conductors �,� O,�,4 A ,�"l, as ox•ner of Ihe property.�rii)do!he,+•ork and the � Other(Sec Complete Fee Schedute).._ s[ructure is not intended or ufYaretl f�v sale (tiection i . �� + • Y �� 7044,Busi�ess and Yrofessions Code). --------- ---- consTHuct�o��.i;n��vc nci:r�<:v -------- f • •y Q 70 1 hercU� affi�m that there is a cunstructinn Iending ugeni}� � � ������ . fur Ihe perf�rmance oF LItL �cork for �chich this perrnit is pERMIT FEE (Sub-Tolall � � � issur.d(Sec.3097.Civ.C.). .��,>l:� r �e�:i u"�i� I Lender's Name -- - �I PLAN CHECKING FEE (One-Fourth Permit Fee� � � Lender's Address i pERMi7 ISSUtNG FEE �,( I cerYiFy tliat[havc rcatl tht.s.i�>plicatimi�nJ state tt�ut qie .�TOTAL FEE J�� � �. aAove informafion is correct.i�gree to comply with,ill Cnunty --- ordinances and St,ite lax�s regulatinR 1•:lectricn! wiring, and . h�neby,nuthori�n represen?atives of thic('ounty to cntcr apon the; ve-mentioned property�f'pr inspec[ion purposus. 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