HomeMy WebLinkAbout1377A WORKERS'COMPENSATIONDECIARATION �6A�3 �o,e, APPLICATIQN FOR ELECTRICAL PERMIT �
� hereby a4firm that I have a cenificate of consent ro self Ce-e06G
insure,or a certificate of Workers'Compensa�ion Insurance, COUNTY OF LOS ANGELES BI��LDIN�'i AND SAfETY
or o ceriified copy ihereaf(Sec.3800,La6.C.)
Poi;��No. C258545�,mPa�Y INA FOR APPLICANT TO Fftl IN JOB
� Cerlified copy is hereby fumished. New Resideniiol Bldgs,8 Pools EACH NO. FEE ADDRES
O Cert'rfied copy is filed with the county building inspec- 1 8 2-Fomily,Sq.FL 1 5(i4 a — S �O�A�� TR�4258 D�$ 88T
� tion deportment. Multi-fpmily Sq.Ft. NEAREST
$�Z�l$6 °T�� McGee Electric Residential Swimming Pools OWNER OR
Date Appliconf
FIRM NAME Anden Grp.
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec_Lighf�Sw._ ���
COMPENSATION INSURANCE First 20 ACIDRE55 1074 Park View Dr.
(Thls�oef{oa nNd not M<amplelvd if�he work involvod by 7otol No. Addifionol CITY Covina, Ca. Tel.No. 96]-9541
tha permN k for ona bundred dollar�(SI00)or lass.)
I cartify�hat in ihe parformonce of ihe work for which this PAL PNCCAHNTK
permit is issued,I shall no1 employ any person in any manner
so as ro 6ecome subjecf ro ihe Workers'Compansolion laws. ��9h�ing Pixtures First 20 ADDR:55
Torol No. Additional
CITY , Tel.No.
I."`'� Applicant Fixed Appliances Not Over 1 HP PERMIT n n
F .:E TO APPLICANT: If, oftar makinq ihis Certificate ot nvaUCANT T McGee Electric, TIIC.
� E.emption, yoo shovld become subject to the Workers' Range_Heater_D.W._
Compensation provisions of the labor Code,you must forrh- Oven _Diyer ,W.M,� ADDRESS P�0. BOg 1].11
i�h comply wilh.such provisions or Ihis�permit shall be Top �FAU —_W.H.—
deemed revoked. Hood —Fan `Other_. QTY Chino 91708 rai.N�g�-646
UCENSED CONTRAGTORS DECLARATION LICENSE OR
Disp. �Room Air Cond. — REG.NUMBER 490083 clo::C-10
I heroby affirm that I am licensed onder provisions of Chapter 9 �
(commencing with Sectian 7000)of Division 3 0#�he Business Power Apparatus 8 Large Appliances DISiRICT NO. f PROCESSE�BY O�
and Professions Code,and my license is in full force and effect. �� V
S�ze 8 Type HP,KW,KVA,or KVAR
License Number 490083 Lic.ClassC-14 �P�o� ���� � FINqL p
Electrical 8�20�$6 Over 1 to 101nd. DATE e�' �' � p��DATION V
Camractor Date Over 10 io 50 Incl.
❑ FINAL W
I om exempt under Sec. Over 50 to 100 Irx. BY �-
B.BP.C.for ihis reason Over 100 Z
� Date: Services,Swbd.,MCC&Panelboards ►
0-200 Amp,Under 600 V
Signmure 201-1000 Amp.Under 600 V -
❑ Over 1000 Amp.or Over 600 V �::� 3 7,7 A
E.emption far Reg.Main�.Elact.
�--. SINGIE FAMIIY Temp.Power Pole 8 Appurfanances r• • e • ♦'�
HOME OWNER-BUILDER DECLARATION . Sign with One Branch Circuit �
I hereby offirm lhai I bm exempt from ihe CoMractor's License Addifional Sign Branch Circuits � i° °7�'C 2
law for ihe following reoson(Section 7031.5,Business and =
Professions Coda): � < <�'�;�(j�.�,
❑ I,as owner of tfie property,will do Ihe work and ihe Misa Conduih 8 Conducrors ��2����
strudure is no� iMended or offered for sale(Sec�ion OTher(See Complete Fee Schedule)_ ►
7044,B�siness and Profestions Code).
CONSiRUCTION LENDWG AGENCY
I hereby affirm thar ihere is o conshuction lending agen4y for
the performance of the work for which fhis permit is issued PERMIT FEE (Sub-Total) 62 5
(Sec.3097,C�v,C).
� PIAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE O S
Lender's Address
I certify fhot I have read this applimtion and s�afe�haf ihe TOTA�FEE 73.Q
above information is mrrect.I agree 7o mmply with oll County
ordinances ond Srate laws regulating Electrical wiring,ond .
here6y outhorize represemotives of this County to enter upon � �
the a�bo�e�'-m',en�i_o,ned, ope,rty for inspec+ion purposes. SEE REVERSE FOR EXPLANATORY LANGUA6E
���O�K'�k� $/Za/8b
SignoWre of Permittee Date
_
'�l,t13� .A �'� f ` i •� ��'� Ntlif� i� ��aA
. .. �� . _ , •.t.. .
��— � �.GfYiNER-BUIEDES2 aECLARFiTION
A'rPRvVAEg � GATE 5lGNATLlP£ � .
., .{.: . . . �_.�.,_�:...�.._. ._.._.__,._..___......
� � ��� .tE Jf F01��R r��E i I hereSy affirm that I anr exempt from the Controcror's
- �- � � � . ,�.�— ----� ... Liconsc Law for the following rcason (SacFloFr 7031:3,
� t,NC...RjLAd�4'Jc .Y 8uslness or,d Proiesslons Code):Arsy Nty or counfy whfch
reOUCfd�Q*1�J T� . � .;�,raqulre,s a psrmtt fa�caosirud,oller,'rrnprove,demolish.
��T� �� - - - -or repo7r pny sflveture,Fr7or to lls lssudr.ce, also re-
. . �W(�+fvK;� � ��`� ft /4�,LF'�' /7�"'�? qu)res the appNmr,t for soch pormH to iife o sfgrted stafe-
...._..._v._.__.:...�� _
merst that he ls pcer,sedptinoartf7o tbe proWsions ol the"
.... .....�
_,. • -'��Fik7tJRE5 -. `.
.__„ ,,,,_.__ ._. Canfraafori Ltten•.e Law(Chapier 9(commvnUng wlfh
� � � '� " �fO1"iC�AU'!-iC�'IZ�D � � � - Sec�7an T{70D?od BiWslan 3 ni the @usMess und Pro��s-
� --- - sians Cod�)ar thet bc!s exampt thers�frpm cnd fAe basis
. . 'UTI!iTYCC3.i'JOTIFIE��� 1or�,ihe of(sged examption. hny Nolotion oF Sselton
F!NA'. ' � 7037.5 by any appl7runf ior a permlt sub/rcts the vpph-
�.. �- ���tlr�.��._� `�"'°�� , cant ta c cAf/!penQlfy of not mora than flvo hundrad
N0T65 � dotfara(55QA)_: —
-. � , . � u!,as owner of rhe property wil!do the wor �d
�� � ��� ��� �- �� �_..�� � � !he strutture is not intended ar o(fored for sale.
. . . � � (Se�a��044,8usdnsssonc�ProfsssionsCode: TheContrac-
__.� � �-� � � � .�,,.., _ _� tor i Llesnse Cow does not app!y ta an owner oi property
-• � - �- -� �� - � � �� . who but(ds ar'Impeovss lhereon, and wha dees sucM�
- _„_i...._. work hPmself provid»:i That suth Fmpravements ore nof
—__::�__.._....__ ...._ —.._ �._�.
- '� �, Irtte»ded or offeref!!vr saJe.t/,however,the butldirg or
� lmprovemesni ro snfd withfn ona yeor of compie!ion,fhy
_..�._.._.__....�._..__. .._.�_..._�
. . � � , owner-bvilderwttlhavethebordenoiprovingtfialhedid
� � _��_�„ _M_ �, not buf�d or 7mpro+e fo[ihe pvrposg of sate.)
'���- - � I am.exe,r.i�t vnder SaC.. � •
�..�..._..__..�.._.__�_— — --- .--------- B 8 P,C. for this reason� �
._... _ __---�.._._.._________..__._�_..._.__ . pate � _�
— . ._..,._ ....__ .�__._... - -- � Qwner