HomeMy WebLinkAbout1384A + ATION DECLARATION 7G4663 �o,e� APP4ICATION FOR ELECTRICAL PERMIT �1
, I hereby affirm fhal I hove o cerfificofe of consent to seli CE-80bG
ins��e,or a ceirifimte oi Workers'Compeosation��su�ance, COUNTY OF LOS ANGELES BUILDING AND SAFETY �f
or a tertified copy thereof(Se<.3800,La6.C.)
P❑olicy NoCZSHSIS�.t Compony INA FOR APPLI[ANT TO FIIL IN qpD 5
Certified co is hereb furnished. faCN NO, FEE
PY Y New Resideroiol Bldgs.8 Pools
QCertified capy ia filed wiih rhe eounty 6uilding inspec- �8 2-Fomily,Sq.Ff. ]..$(�3 S — x �O IITY
tion department. Mulli-fomily Sq.FL NEA Si
n n Residential Swimming Pools CR0.5
Oa�e 8�2��$b qpplicant T mcGe�Ele�tric OW'NEROR
FIRM NAMf
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlefs:Rec_,_Light_Sw._ MAiI
COMPENSATION INSURANCE npDRESS 1074 Park.View DI.
(7hi��acfion nvad nof bo tomplatod if tha work Inrolrad by fird�20 CITY
fNv p�rmit is for om hundr�d dollars(5100)or lau.) Totai No. Addiliona� Covina, C$. 1ai.No.967-9541
1 cartify ihot in�he per{ormance of the work for which this AA�NCC�HNTK
permi�is issued,I shoil not employ any perso�in ony manner
so as Io bemme subject ro the Workars'Compen:atioa Laws. Lighiing Fixtures Firsf 2D ADORES$
Total No. Additionol pTY Tel.No.
P" qpplican� Fixed Applionces Not O�er 7 NP PERMIT �� ��
i, .,CE TO APPLICANT: If, ofler moking this Ce�+ifiwte of � ApP�iGqNT T HcGee Electric
Ezemption, you should be<ome wbject to fhe Workers' Raoga�Heater_,_,_D.W._
Campensation provisions of ihe labor Cade,yau musf forfh- Oven �Dryer _W.M._... ADDRESS p��. $OA Ill.�-
ith comply wi�h suth provisione or Ihis permif shal) be Top _.FAV �W.H.�
deemed revoked. Hood .�Fan _Other� C�rr CIl�IIO 9�.IOH tei.No.591-6461
LICENSED CONTRACTORS pECLARpTION LICENSE OR
Disp. _.Room Air Cond. — REG.NUMBER 440�83 Class. C—I.O
I haraby affirm thol I am licensed under provisions of Chpp�er 9 }
(commencing with Section 7000�of Division 3 of the Business DISTRICT NO. PRQCESSED BY n-
ond Professions Code,and my license is in fuU force and effect. Powe�Apparatus 8 Lor9e Appliances Q
Size 8 Type HP,KW,KVA,or KVAR� /� V
490083 C-10 a
License Number Lic.Closs FINAL
Up to 1 Incl. Gj
Electrical 8/20/86 o�e��ro IO Incl. DATE ,2 y �"�' �
VALIDATION
Controctor Date Over 10�0 50 Ind. FINAI w
❑ I am ezempt under Sec Over 50�0 100 Inc BY �'
N
B.&P.C.for fhis reoson Over 100 Z
Dote: Services,Sw6d.,MCC 8 PaneiSoards ►
0-200 Amp,Under 600 V
Signoture 4Q1-1000 Amp.Under 600 V
aOver 1000 Amp.or Over 600 V
Exempiion for Reg.Moint.Eleci. r�j E.(J.A
�'"' SINGLE FAMILY Temp.Powe�Pole&Appurlendnces
HOME OWNER-BUILD€R DECLARATION #'' e t "��
Sign with One 8ranch Ckc�it
I hereby affiirm that I pm exempt from the Controctoi s license Additional Si9n Branch Cirtaifs 1 k��4 7��2
Law for�he following reoson(Secfion 7031.5,8usiness and
Professions Code): � � � ��
� Misc.Condulrs 8 Canduclon � � �"��� ��
I,as owner of 7he propeny.wiil do the wo�k ond ihe
shuciure is nm intended or offered for saie(Sec�ion Othai(See Compleie Fee Scbedufe)_ , Q�1,2�..�j 6
7044,Business and Profesaions CodeJ.
CONSiRUCTIpN 1EN01NG AGENCY �
. I hareby affirm thot there is o mnstruc�ion Iendi�g agency for
the paiformance of�he wo�k tor which this permi�is issued p€RMIT FEE (Sub-Total) 62 52
(Sec 3097,Civ,C.). �
� PLAN CHECKING FEE
Lender's Name
PERMIT ISSVING FEE LO SO
Lender's Address
I certify Iho+I hove read fbis oppliwtion and sfale thaf Ihe TOTAL FEE - 73.�
a6ove informa�ion is rorrect.I ogree to comply with all Coony
o.dinonces and Store lows regulating Eiecfrieol wiring,ond
hereby aWhorize represenlotives of�his Coumy to enter upon
the a ve-mentione propeny for inspecrion purpases.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Si�� � � 8/20186
oi 7ermir , Date
' ++.a� � . ` ' . � !1C � �+C ;',A�11`'1A
, �R. R�VAIS ..�~ D/a7E .� - . �OWNEP.-BUtlp£R��
��
. SlGP1A7tiFCE �
� � - '- �-� � � I herob p$irm tha!l am exempl from tho Canlraticr's
� rF.",K PONFp ACLE .L_. � y .
Licensa Law for ihe foilowing reaso� (Sechon 7031�5,
�UNUF 'A�3 Ys0€K � . . ... .� ^~� .. . � . guxiness ar,d Profess�onx[qdn}:Any ctry o�county which
!ROUG.f CC"J�tJ!i y I . requlrosp pormif to consirutl,pffer,improka,demo�isfi,
-----{ or tepofr-any�strurtture,prior fo f6 tssuvnca,oiso re�
' � �NII�n��.G�� f, f T a'�•,.. ------- 1 9utre;the appllmrt for wch psrmit fo fiIo a stgned sfate�
�""� mont lhat he!s Arensed puauant tp tha provtsbrts of�he
. A .- !k"�r�tt$ '- �� ~^_� Coniractor':Llcense taw(Chapte�9 framm�nUng w�rh
-' � �I�PO\5E�7�'L�i21ZE0 � . � Section 7400)ot Dirlslon 3 0/the 8aslness and Prohs-
sions Cade)ar lhnt he fs exsmpt theralrom and>he basis
t171JT�'CO N�TI=IcG� 1or thn a!legmd exemption. Any viola3ion o!Sae+lon
fe7 7C31.5 by any aCplfwn4 fe:a permR sub}xts ihe appli-
�'r"�A� ,. � f nS`e�r an.,y-rvnC i , cant io a Nvil pertalty of naf mora lhert five hundred
NOTFS da!lars{$Stl0).: .. —.
� � �. ❑I,as awne*af the praperty will do tha won ,�d
�'�_ �' � � �-' ,��,�_ !he str�tture is not intane�s+d ar offarsd for s�te.
;�- . � - (Sec.70#4,6uxlnese attd Professfons Code: ihe Confroc-
_____i � ' - __ tor's Lfaonse Low ches rsot appfy fo an awnw o!properfy
.. . . � .. � . ,,�.�� who bWlds or'improves ffierecn, and whe does such
__ - _____. _ ^__ _ wnrk filmse!f prcv�drd thaf such(mprovements are nof
. .. . � � - iMendrd or otFare�S for safe.1/,however,fhe butfd;ng or
�_ � ���_ �� _ 7m�ruvemeM Is sn(d wtfhin one yanr o!tompfefion,Ihe
. _ � � , ownervEvtlder wrl7t have tbe 6urden aip:oving thot he did
� � � �u nnf bu11d or lmpra�ro for ihe purposn of saia.)
� � �,_..`T� i arrr,r.�Cempt under Sec. - � ... ,
---. � —.---.-------------------.--- - . B&?.C,for this roosan �
____._�,�..... _�_. .__...._.....u...�..._.._. ._ . Date_
— '--- --.___�.—._ �..___._.__..._._.�__.�. . � . Owner _