HomeMy WebLinkAbout1727 SILVER RAIN DR (4) WORKERS'COMPENSATION DECLARATION �E� ���8t p�pp��CATl�R� F�P €LECTP.iC�L �E�MIT � i
I hereby affirm tha� I hove a certificafe of cansent to self �/
insure,or a certificate af Warkers'Compensation Insuronce, COUNTY�F,qOrs:1NGELES BUILDING AND SAFETY �
or a certified copy thereof(Sec.3800,La6.C.) I
POolfcy No. Compony FOR APPIIGANT TO FILL IN ADDRE55 �/Z S�1��I` /�'� R
Certitied copy is here6y furnlshed. New Residen�ial Bldgs.&Poals EpCH NO. FEE
� Cernfied copy is filed with tha county building inspeo y,Sq. LOCALITY
1 8 2-Famil Ft. s — $ � B
NEARESi /��O J��
tion departmenf. Mulfi-famify Sq.Ft. CROSSST./�) G Q�1+
Residaniiol 5 ming Fools OWNER OR
Dote Applimnt � Q�� aO FIRMNAMEG+�'� �dN��R
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec_Lig�Sw._ �^�� �'�L ��� � �
COMPENSATION�NSURANCE /�DttE
(Thts seefton need nN be complW�d N th�work Invdrod by Firsf 20
tlw pormN Is ior onv h�ndrod doliws(SIOa}w{vs�.) 7otal No. Additional CITY / �{p�((�/� TeI.No.��l Z¢
I certify that in�he performance of the work fw which this PtAN CHECK � �
APPLICANT
permit is issued,1 shall not empioy any person in any manner
so as to become su6ject to the Work�rs'Compensation Laws. Lighling Fixtures Firsi 20 AD�RESS
�,�„� �s�y��/yle� Total No. Additional
Da�e °PPGcont_ —r��l�� CITY Tel.No.
NOTICE TO APPLICANT: If, ofter making this Cer�ifico�e of Fized Appliances Not Over 1 HP PERMIi
Exemp�ion, you should 6ecome su6jec� to ihe Workeis' Range_Heoter_D.W. _ AP���M
Compensation provisions of the Lobw Code,you mus�forih- Oven _Dryer —W.M.— ADDRE55
wilh comply with such pro.isions or this permit shall be Top _FAU —W.H.—
deemed revoked. Ha� _Fan _Orher_ CITY Tel.No.
UfENSED CONTRACTORS DECLARATION u�NS�pR
i heraby offfrm thot 1 om licensed under provisions of Chapter 9 Disp. �Room Air Cond. — REG.NUMeER Class. �
(commencing with Section 7000)of�Ivision 3 oF the Business DISTRICT NO. PROCESSEO BY �
ond Rofessions Code,and my ficense is in full force and effed. Power Apporafu5 8 Large AppHcnces �.
Size 8 Type HP,KW,KVA,or KVAR �� � �
License N�mber Lic.Class Up to 1 Incl. FINAL � U
Coniractor Da�e Over 1 lo IO lncl. DATE ��l �j YALIDATIQN � �
� Over 10 to 50 Ind. FINAI O �
I am exempi onder Sec. Over 50 to 100 Inc. BY `Y^\(� w �
B.BP.C.for this reason Over 100 ` ,\� �A"� �
N
Services,Sw6d.,MCC 8 Ponelboards � z �
Dare: 0-200 Amp.Under 600 V �
Sigrature 201-1000 Amp.Under 600 V
❑ Over 1000 Amp.or Over 600 V �
Exemptian for Reg.Mainl.Elect.
!
S�NGIE FAMILY Temp.Power Pole 8 Appurtenances �
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
1 hereby affirm that t am ezempt from�he Contractor's License p
law foi the following reason(Section 70.?i.5, Business and Addilionol Sign Bronch Circuits '�c'- ������
J Prof ssions Cade): �� o � e �� �
• 1 Misc.Conduits 8 Conductors �
]\ 1,as owner of the property,will do the work and the �n�r+
I structure is not intended or offered for sale(Section Oiher(See Complele Fee Schedule)— � � o •�.�,��.
7044,Business ond Professions Code�. _ _
CONSTRUCTION LENDMG AGENCY � � �`�`�J''�
I hereby affirm that there is a constructian lending agency for ��_^^
the performance of the work for whith�his permi�is issued PERMIT FEE (Su6-Total) ��Y��
(Sec.3097,Civ.C.).
PtAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE
Lender's Addrass
I certify thot 1 hove reod this application and state thot the TOTAL FEE �
abo�e information is correcf.I ee to omply with all County
ordina ces and State law egu t� lectricol w��ng,and
here aulhorize represe afiv t ' County e er upon
� ove-memion er r� pectian urp es.
� SEE REVERSE FOR EXPLANATORY LANGUAGE
' c.�.,,... � �z^�
$ignature of Permittea Dote i
�vl y i Oi m� .r't. N O � m C " �Y O O-�C� �
o� � � ` �6 ;� a a�` a ° � „ ` �"� ,�'
00 0 �«o �o.a v o c Y c o„ m � cr
^ �m�d e ���y m.c `o U `a m °� m.c
U ° p� $�� o o e ° M i m m-c °-° �'° a
Z m � v > � '" "> E M o e "t, _' s o�- `m_c° E� E e�
O �`�" >a«� aO �°°�_c �r°-v 3 3 ' `'- � N
Q E e .. E m�•N a � � o o� o � o ao
� o N i, � o�p, � �' � .,, m -�V c o a m � d
g ''L_ '° " � � 3 � �0 � ° ° o
U a:'Q � oE � ::.01c� cmE �'� o o.e_c° ''ma
� X ca� o a�.e o Ea o 0 0`o� ad �= o.a a
a� 3o5�.ezv,.� xo ` � a-000som _ m�
� o�c � am „,eeN "'Zw� Scvcm� a�=p� � m o
7 p O G � W�I � pC � CI G N ?� Q 3 >M fn N If
m m .N u �.� �n >.�c CI �+O O c � d �a ti''O U 6 m
W ��,m °?p � eoomn.a�+ �, `om�' Eo�°�' °= O � y :
3 �•°a` E a.a=� ° :.d °a.. 3 N„� � aw = � E � s I
��'>-�o • � o= o m - a �
� " 3 c �o u.e° hR�.°�= a ua a m°° m N „ o mt' o E .° I
T.9 „ ��� o oa o o�o."'�n_v� �� £a ��'v_ X j
� m m � ��+ o �v.@c�n +° � �nJ.'a-�� > m � � V E m
:' � e� e � � : ° � �- o� � ,; „ o.� c ° �-o � a y c
s J � °�� a ° o m o �o 0 0 o m �s o m a oa 3
_ - m � o vEu�n �..4n u-o �'�'.° 3 3 � E o c° ° m a O
�
�
+' a
z
�
�
�
C
�' V 1
�
C
0
i
m
w
�
� W
� Y N u.
a �a O � � O
O W 3 � _' z
a 3 g U N ¢ �
a g �n = c� w ��++
a � � OZ-[ � 5 � Q �
' �k-" � � 3 LL a � � �z
.