HomeMy WebLinkAbout1381A WORKER$'COMPENSATION OECIARATION �6A�3 ,o.B� APPLICATI4N -FOR ELECTRICAL PERMIT �
I hereby,affirm Ihot I hove a certificate of consenl b self CE-806("
i�su�e,o�.a ce�rfimte of Wo�ke�s'Compeosarion Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or o tenifiad mpy fhereof(Sec 3B00,Lob.C.)
a�Y N625859571 Company I�A FOR APPLICANT TO Flll IN JOB
Certified m s hereb furnished. EACH NO. FEE ADDRE
PY' Y New Residential Bidgs.8 Poois
� i x z-Fam�i s Fr. 15�� s _ s �ocn� v TR�4258 Dia Bar
Cenified copy is filed with ihe counry building inspet- Y� 9�
tion departmenl. MuNi-fomily Sq.FL NEARfST
ResidenlialSwimmin Pools CROS55T.
pa188/20/86 APPi;�a�i`T" MeGee Electric 9 OWNEROR
F�RM NAME
CERTIFICATE OF EXEMP710N FROM WORKERS' Outlets:Rec_Light_Sw.,_ MAit
COMPENSATION INSURANCE Firsi 20 A�DRE55 1074 Park View DT.
(Thls aoci{on nwd nof be comploted if fhv work involvad by Total No. Additionai CITY Covina, C,a, rei.No.g67-4541
�he permit is for one hundred dollors(5100)or losc.)
I certif thot ia lhe formance of Ihe work for which this PtAN CNECK
Y P�'� APPLICANT
permii is issued,I shall not employ ony person in any manner
so as to bacome subjecf to the Worked Compensation Laws. ��ghfing fixtures First 20 ADDRESS
Total No. Additional
�... CITY Tel.No.
APP11C°^� fixed Applion[es Not Over I HP GERMIT �� u
_i,CE TO APPIICANT: If, after making this Certifiwte of APPUCANT T MeGee Electric, TAC.
Exemption, you should bacome subject to the Workers' Ronge_Heater_6.W. _
Compenso�ion provisions of the Labor Code,yob mus�forih- Oven _Dryer _W.M., ADDRESS P,Q, $qX ,lljl
wi�h comply wi�h wch provisions or fhis permit shall be roP _Fnu —w.H., 591-6461
deemed revoked. Hood _Fon _Other_ CITY (',t11110 9�.7�$ Tel.No.
LICENSED CONTRACTORS DECLARATION UCENSE OR
I hereby aHirm thot I am licensed under provisions of Chapter 9 Disp. _Room Air Cond. — REG.NUMSER Closs. � }.
(commencing wilh Section 7000�of Division 3 of the Bosiness power Apparatus 8 Large Appliances DISTRICT NO, PROCESSED BY n-
ond Professions Code,and my licansc is in full force ond effect. / � U
Size 8 Type HP,KW,KVA,or KVAR� G
License Num6er 490083 ���,Closs C�lO � FINAL �
Up fo 1 Ind.
CoMractor Electrical ��e 8�2��86 Over 1 to IO lnd, DATE � Lf.� �"7 yppDATION W
O Over 10 to 50 Ind. fINAL
I am exempt�nder Sec. Over 50 to 100 Inc BY �
�
B.flP.C.for this reason Over 100 z
Da�e: Services,Swbd.,MCC 8 Panelboards �
0-200 Amp.Under 600 V
Signature 201-1000 Amp.Under 600 V
� Over 100p Amp.or Ovar 6W V
Ezemption for Rag.Maint.Elect. �'1 3�1 A
� SINGLE FAMILY Temp.Power Pole 8 Appurtenonces #!o • s a<'�
- HOME OWNER-BWIDER DECLARATION Sign with One 8ranch Circui�
t hereby affirm thot I am exempt from the Contractor's License qdditional Sign Bronch Circuin � � A 7�.�2
low for the following reason(Section 7031.5, Business ond
Prafessions Code): . � � � . �J��.�j
❑ I,as owner of ihe ro ert Misa Gonduils&Conductors �
p p y,will do ihe work and fhe Other�See Complete Fee Schedule)_ � ��j�.�'�-8(�
struc�ure is not intended or offered for sale (Section .
7044,Business and Professions Code). ,
CONSTRUCTION LENDING AGENCY
I hereby affirm thol ihere is a mnstruction lending ogency for
the performance'of the wark for which this permit is issued pERMIT FEE (Sub-Total)
(Sec.3097,Civ.C.).
PIAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE
Lender's Address
I certify thar I have read this applicaiion and stote thot the TO�AI fEE 73 Q
a6ove information is mrreU.I agree Io comply with all County
ordinonces and Sfpte lows reg�loting Elecfricol wiring,ond
hereby au�horize representatives of this Coumy to enter upon -
the bove-mentio d propeny for inspeclion purposes. SEE REYERSE FOR EXP�ANATORY LANGUAGE
� � 1r sl2o/s6
Signature o4 Perminee Date _
� ��1f�� � , � � 1i � � . ' �Ill�? j� � ���
� ' a�€� c�VAlS oA7E � ' OYdhIER-BUILDER DECLARA710N
,� � _., L..._._. � � . _._.__ SlC�AttaR@
.. . . � � � - �Tvtd�F PQVeR PiLP.�_ �.�..� ,. �. - � hemby af#irm�hat I am exempi from fhe Confractor's
. . . , - �-,,,. , . . . l�cen:s Eow tor the following reason (Soction 7037.3,
LN`�tRSiA9�.�:'iRK I Y 8uslnezs cnd Prolessions Code):Any clty or to�nty wAich
�ROUGFi Cp J�U'T �� , repulres a permif ioronsiruri,aifer,7mprove,demofish,
---���------ ar�rbRa(r vr.y-slrocture,prior!o Its lzsuance, ofso re-
i���������-���-��� /p�/p.�' v�V puires the appSfcanf(orwch permlt ro f/le o sfgrted sfote-
(-'-"'-""'-" � . mant thof he Is l7censad purwant to the provlslons vf thv
' ' - �� F!X(i7nES � Confracfori t]tense Law(Cbaqter�fl(comnm+cing w/ih
� �-� `� I�JTtiC7;Zi�D � Sec�ion 7000J of�DiWstan 3 af ihe Buslness w:d Profwc�
r-�-�-- � - sionz Cade)or fhat hc Is exempt iherel;wn ond!lw basis
U71LIf TYC�e'�'QT�F}`U � Var it;e alleged exempflon. Any violofion of Seclton
�F�RIA; � r7 T031.5 by orsy appfltant i�sr a p�rmii sub(eNa the Rppll�
i .....�_-_��'�"'"".^j�rO°'� cant fo a c�vlf panalty al rtot more�hon Rve hundred
NGTES dotlars(S5Q0}.: -.
� , ,I.: ' . � � ❑i,os owner o{the property wilt do ihe wor�., ..d
" ,� "�� � � �� � . tna struUare is not iniendod or offared for sale.
� -. . (Sec.7D44,8uslness aod Professfons�ade� The ConNoc-
_._`�' '� �_ � . sor's lieensa!ow does nat opp(y�a on ownar of prop�rty
.. . ... , . .. � � who buttds or�rmproves �hereon, and who does:uch
�� - ,___ work himseff providt3d thaf such Improvempnls are nos
, . �� � . � � intendad or offerad/or sa�e.fI,however,fhe bvllding or
� ��Wi. ��,__ � impravemerei ts so(d wrthin one year af complsfion,�he
� owner-6o11der wtf!have the 6orden ot proving tho�he d+d
�� � � ______ � not bvt/d or tmprave ior thv purpos3 of sa(e.)
_ _._._.___ .�.__�:_.__._�_._.._.._. ,1 am exempt under Se�, :.. . ,
i .
�.� ...______.�.�.------_.���..�_._,..._._._.__...—__._..__.._ B 8 P.C,ior t6is r�ason
_ ---____._.....� _._._..._._._.�..._._.___ qate�. __
.. .__._—_____W.. ____.._._...�____._._. .- � Owner
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