HomeMy WebLinkAbout1371A . MPENSATION DECLARATION 76A663 �o,a� qpp��CATIQN FOR ELECTRICAL PERMIT ,Cpf f � �
I hereby affirm fhat I hove o certificale of conseN lo self CE-806G
insure,or a certifimte of Worke�s'Compen-csation Insurance, COUNTY OF LOS ANGELES BU�LDING AND SAFETY
or.a ceriifi�o�y��+er�ef f5ec.3800,t°ktLYA) .
P❑olicy No. Company FOR APPtiCANT TO FILt IN JOB
Certified topy is hereby furnished. New Residential Bldgs,8 Poq I EACH NO. FEE ADDRESS I+Ot ].3 T�Od. � Armitos Place
� Certified copy is filed with rhe county building inspet- ��2-Fomily,Sq,fl. 1L�5 S — $ sj LOCAI,ITY TR�fk2584 Diamoad Bar
tion depqrtmem. Mulfi-family Sq.FL — NEAREST
7�12�85 °T�� McGee E1ec. Resideniial Swimmin9 Pools ' ceo555T.
Date Applicant OwNER oR
fIRM NAME Anden CiY'011
CERTIFICATE OF FXEMPTION FROM WORKERS' Outlets:Rac�Light?Sw.? ��`''�'��
COMPENSATION INSURANCE � (� (� cJ0 A�DRE55 1074 Park View Dr.
First 20
(Thtf saclion naed nof M comple4ed if}he work inrolrad by To1a�No. 6 Addifionql CITY Covina 91724 rei.No.967-4541
th�p�rmif ic for ona hundrod dollan(5100)or��s�.)
I cerlif Ihal in 1he erformance of Ihe work for which ihVs PLAN CHECK
Y P APPLICANT �
permit is issued,I shall not employ any person in any monner
so as fo become su6jecl to the Workers'Compensation Lows. Gghling Flxlures2 Firsi 20 1•5� qDDRE55 �
� To7al No. Additional
. o ��a� pTY iel.No.
,�'''M' PP Flxed Appliantes No1 Over 1 HP PERMii . ❑ R
ICE 70 APPLICANT: It, aftar making this Certificate of A����P,n. T McGee Electric,Inc.
Examption, you should become subject to Ihe Workars' Ronge.._.Heoter_D.W._
Compensation provisions of�he Lobar Code,you musl forth- Oven _Dryer —W.M._ ADDRESS �,0. $pX 1111
with comply with such provisions or this permi� shall be Top �FAU —W.H.— �
de�med revoked. Hood _Fan .�O�her_ CITY Chino, G�d. 91�08 Tel.No.$J1-646�.
LICENSED WNTRACTpRS DECIARATION tiCENSE OR
1 hareby affirm that I om licensed under provisions of Chaprer 9 Disp. _Room Air Cond. � REG.NUMOER 4207�$ Glass.C-1�
. (commencing with Section 7000)of Division 3 of the Business pISiRICT NO. PROCESSED 8Y .
and Professions Code,and my license is in fuil force and effed. Power Apparatus&targe Applian<es �� 4
Size 8 Type HP,KW,KVA,o�KVAR� � �
Litense Number 420748 ��c.Class C'�10 FINAL V
Up fo 1 Incl,
Electrical 7/12/85 o�e�i fo 101nc1. DATE j�, �3/�S VALIOATION Q
Coniractor �ole Over 10 fo 50 Incl.
❑ PWAL
I om exempt under Sea Over 50�a 100 Inc. BY ��/�'��/ wi
B.$P.C.for Ihis reason Over 100 � � N
Services,Swbd.,MCC&Panelboards , �
Dore: p-2pp Amp.Under 600 V �
Signature 201-100p Amp.Under 600 V
❑ Over 1000 Amp.or O�ar 600 V
Exemption for Reg.Maint.Elect.
� SINGLE FAMILY Temp.Power Pole&Appur�enonces #��3�'��
HOME OWNER-BU�LDER DECLARA710N Sign with One Branch Circuil ( s= -
i,__.eby affirm thot I om exempl from 1he Contrador's Liwnse Addiiionol Si n Bronch Circuits U',t���g v
Law for 1he following reoson(Section 7031.5,Business and 9 '
Professions Code): % 2
� Misa Conduits 8 Conductors �✓�•✓v
1,as owner ot Ihe property,will do�he work and the
structure is no�intended or offered for sale(Section Other(See Comple�e Fee Schedule)_
7044,Business and Professions Code). � ']� ��—�S.
�
CONSTRUCTION LENDING AGENCY .
I hereby affirm that there is a construction lending agency for
the performance of the work for which�his permii is issued PERMIT FEE - (Sub-Tatal) 5]� Q
(Sec.3097,Civ.C.). � �
PLAN CHECKING FEE � � .
Lender's Nome �
PERMIT ISSUING FEE
Lendar's Address
I certify thot I have read ihis applimfion ond state thaf the 70TAL FEE ' .
obove informotion is correcL I ogree ro comply wiih pll Couniy
ordinpnces and State laws reguloting Electrical wiring,and � .
here6y authorize represeNatives of ihis County to enter upon - �
the a ov�ntion�operry for inspec�ion purposes. SEE REVERSE FOR EXPLANATORY LAN6UAGE �
�' � 7�i1��S/
Signature of Pormiflee Dafe � �
. ' _ ' ' � —- �� a.�� .��/r�1�r.� •e � f•'4. 4,.`*�+ �,�
� � �� �.'nPPROVpts DArE —�8R �OWNER-BUILDER D€CLlCRA7'K7R] �
� � - � SIC ATURE
� � � . � � 7EMF.POWER POLE I hareby affirm thot I am exempt from the Coniroctar's
� - licenss Lnw for the following reoson (Socflon 7031.5.
. UNDERSLAB WORK � 8usfn�as ortd Pro/essions Code):Any dty or wunty whkh
ROUGH CONDUIT � raqufros a permlt fo consTruct,alter,Improve,demolish,
•�or rspofr any sfiructure,prior to Hs �szuan�e.'ofsa ra-
_�. WIRING � F� ��j' f�,� " , qulrnihoappllmntforsuchp�rmittoiileasigneds�ate-�
. FIXTURES � m�ntlhaf hs is litans�dpursuant ic the provisfons of ihe
, � ..- �� Confroetof's Ue�nss Cow(Chapter 9(commandng wlfM1
POV✓ER AU7HORIZ€O SeN1on 7000)of Dlv(sion 3 of the Business ond Profas-
.._� sfons Code)or fhofi fie Is exempt�hore/rom ond efie bosis
UTILIN CD.NOTIFIED . , for the aflaQsd exempiton. Any viofaflon of Sectlon
FINAI � � 7031.5 by any opp8cant for a permlt subjeds the appl�-
nfer on rortt cant fo a civfl pertaliy of nof moro fhon live Irundred
� NOtES � dol(ars(SS00J.:
.:��.��. :..��..� -�.: ` . ' ❑1,as owner of ihe properly wiii do the work ��!
the siructure Is net imended or offered for sale.
_. . .� (See.7044,&uslness ondProfesslons Code: The Conirac-
� � for'a Llcense Law does not opply fo an pwner of property
� � -� � �� - " . � who bWlds or Improves thereon, and who daes svch
� � " work hlmself provlded Thaf such�mprovemen/s ore not
. � Intended or offeredfor sofe.H,however,fhe buifdtng or
improvemrnf Is sold w7tRln one year of complet/on.}he
. ownor-build�r will have fhe burden of proving ehot he did
rrot!wlld or Improve for fhe p�rpase of sole.)
I am exempt under Sec. ,
B 8 P.C.for ihis reason
Da1e
Owner