HomeMy WebLinkAbout9999AWORKERS' COMPENSATION DECLARATION 76A663 10!81
I hereby affirm that I have a certificate of consent to self insure,
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or a certificate of WorkersCompensation Insurance or a car' of C
copy th of (Sec. 3800, La . C.1
Policy Compan
CATION FOR ELECTRICAL PERMIT
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Certified copy Is hereby fur n hed. New Re,
Certified copy is filed with the city building inspection 1 & -F F
division. Multi"- II
DateCA!7Jf40 Applicant Residential Swimming Pools
CERTIFICATE OF EXEMPTION FROM WORKER tlets. Rec Light Sw.—
COMPENSATION INSURANCE ' 1
This section need not be completed if the work involved by the
First 20
permit is for one hundred dollars (S100) or less.) Total No . Additional
I certify that in the performance of the work for which this permit
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is issued, I shall not employ any person In any manner so as to
TOTAL FEE
become subject to the Workers' Compensation Laws. Lighting Fixtures First 20
and State laws regulating Electrical wiring, and hereby authorize
Total No,
Additional
Date Applicant Fixed Appliances Not Over 1 HP
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers' Compensation Range_ Heater_ D.W. _
provisions of the Labor Code, you must forthwith comply with such Oven _ Dryer _ W.M. _
provisions or this permit shall be deemed revoked. Top _ FAU _ W.H. _
LICENSED CONTRACTORS DECLARATION Hood — Fan _ Other_
I hereby affirm that I am licensed under provisions of Chapter 9 Disp, — Room Air Cond.
commencing with Section 7000) of Division 3 of the Business and
Professions Code, and my license is in full force and effect. Power Apparatus & Large Appliances
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Size & Type HP, KW, KVA, or KVAR
License Number Lia Class . Up to 1 Incl.
A Over 1 to 10 Incl.
Contractor a e Over 10 to 50 Incl.
S^ 1 an exempt under Sec Over 50 to 100 Inc.
BAP.C. for this reason Over 100
Services, Swbd., MCC & Panelboards
Date: 0 - 200 Amp. Under 600 V
Signature
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201 - 1000 Amp. Under 600 V
Over 1000 Amp. or Over 600 V
Exemption for Reg. Maint Elect.
SINGLE FAMILY Temp. Power Pole & Appurtenances
HOME OWNER -BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License Law
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits
Code):
Misc. Conduits & Conductors
I, as owner of the property, will do the work and the structure
is not intended or offered for sale (Section 7044, Business Other (See Complete Fee Schedule) _
and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the
Tel, No.
performance of the work for whic this permit is issued (Sec. 3097, PERMIT FEE
Civ, C.).
4N.,07119- e Nc.
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PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE
Lender's Address
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I certify that I have read this application and state that the above TOTAL FEE
information is correct. I agree to comply with all city ordinances
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and State laws regulating Electrical wiring, and hereby authorize
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representatives of this city to enter upon the above-mentioned
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property for'nspection purposes.
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SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date I
FEE
ADDRESS
LOCALITY
NEARESTCROSSST.
I ADDRESS
CITY
PLAN CHEC
APPLICANT
ADDRESS
CITY
PERMITAPPLICAN
ADDRESS
CITY 4!
CENSE OF
REG. NUMB
FINALDATE
FINALBY
Tel. N.Iif
Tel, No.
4N.,07119- e Nc.
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APF BpVA DATE INVGNATUP%
TEMP. POWER POLE
UNDERSLAR WORK
ROUGH CONDUIT
WIRING
FIXTURES
POWER AUTHORIZED
UTILITY Co. NOTIFIED
FINnI. Enter on Front
NO _IES
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt front the Contractor s
License Law for the following reason. (Scc. 7031.5) Bdsi.
ness and professions Code: Any city or county which re-
quires a permit to construct, atter, improve, demolish.
or repair any structure, prior to its issuance, also re-
quires the. appheart for such permit to file a signed
statement .'that he is licensed pursuant to the 'provi-
sions of the Contractor's License Law (Chapter 9)
comxencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he is exempt
therefrom and the basis for the alleged exemplion. Any
violation of Section 7031.5 by any applicant for a permit
subjects she applicant to a civil penalty of not more than
five hundred dollars ($500).):
0 I, as owner of the property will do the work,
and the structure is not intended or offered for sale
Sec. 7044) Business and Professions Code: The Cnn-
tractor's License Law does not apply to an owner of
property who builds or improves thereon, and who does
such work himself provided that such improvemenis are
not intended or offered for safe. ff, however, the build-
ing or improvement is sold within one year of eomple.
tion, the owner -builder will have the burden of proving
that he did not build or improve for the purpose of sale.)
I am exempt under Sec.____.. ,
B R P.C. for
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Date