HomeMy WebLinkAbout0962A WORKERS'COMPENSATION DECLARATION 76A663 ,�,a, APPLICATION FOR ELECTRICAL PERMIT � I hereby affirm ihat I have a certilicate of consent to self insure, CE-sosG � or a ce�liPicatc oi 1Vorkers'Comoensatan Insurance,oi a wrtitied COUNTY OF LOS ANGELES BUILDING ANp SAFETY .copy lhereoi(Sec.3800,Lab.C.) . 1003782 STATE FUND Fon AvaucnNr ro Fa�u+ �os �Po�icy No. compariy 24212 BRECKENRIDGE LOT 21 ❑ Certilied copy is hereby furnished. . , New Residential 81dgs.&Pool EACH NO. FEE AOD�ESS �'7 1 S 2-Famil s �636 g . _ g LOCALRY . DIAMQND SAR TIt 42571 �¢ Certilied copy is filetl witb the county building inspection y. 4�FG � "^X d tmer� ��' � Multi-family Sq.Ft. — NEARE57 � ��--t�,'—�� E & D ELECTRIC ICN. Res'WenGal Swimming Pools caoss sr Oate AppliCant °�"�q�R M.T. BROCK &SONS INC. .�.: ` �- � - FlRM NAME � � CEFTIFlCATE OF EXEMPTION FROM WORKERS' putlets:Rec�Light—Sw.- - � �� ��� � � COMPENSATIONINSURANCE � � . ADDR[SS P.O. I3OX 3SO Firs[20 �. (This sedba need not be completed H the work InvoNed by the 7otal No. Additionai q7Y.. . Tel.No. , rermil is for one hundrad dollars(f 1001 a bes.I 1 certi(y Ihat in thc perio�mance of the vmrk forwhich ihis permit '. PUW CNECK _ APPLICANf is iseued,I shall not employ any person in any manner 5o as to . become subiect to ihe Workers'.Compensation Laws. � Lighting Fixtwes First 20 - A�DRESS - . . Atlditional � � iotal Na � GTY Tel.No. � � Applicant � � Fixed App�iances Not Over 1 HP vEkMiT ��n..�iCE TO APPLICAN7: It, aiter,making this CertOicate ot AP�1�M E & D ELECTRIC INC. .Exemptfon,you should become subiect to the Wwkers'Canpensation Range_Heater D.W. _ provis�ons ot the Wbor code,you must torthwtth cwndy with such Oven_Dryer_ W.M._ ADDRESS 3J 9 r1C ARTHUR WAY ��1 provisions or this permit shalt be decmed revoksd . Top _FAU _ W.H._ . .. �.LICENSED CONTRACTORS DECLAflATION Hood_ Fan _ Other_ ��TY [Jp Tel.No. I hereby alfirm that I am licensed under proviaions of Chapter 9 uCenSE OR Disp.�_RoomAilCord. _ REG.NUMBER 422589�-� � c��s. C-10 (commencing with Seclion 7000)of Division 3 0l the Business and , - PlOIe55i0n5 COde,altd my IIGCnSe IS irl�UII�O�CC 2fld¢�12CI. OISTflICT NO. ' Pf70CESSED 6Y Power Apparatus&Large Appliances . _ � . Size 8 TyOe HP,KW.KVA,or KVAR ,D p,�O n � License Number 422589 ��.ciass C—lO - �Up to 1 IneL FINAL E & D ELEC C.�.-�!� `g.� Over 1 to 101nc1. �TE � VALIDA190N � Contractu: Date pvcr�10 to 50 Intl. � FI L / V ❑ I am exempt under Sec. Over 50 to 100 Ine. � BY. - _. W B.6P.C.1or this reason Over 100 a. N Services,Swbd.,MCC d Panelboards ►� - � - � --� Z Date: � 0-200 Amp.Under 600 V Si9nature 201-f000 Amp.Under 600 V � � - �� � ❑ Over Y000 Amp.ar Over 600 V Exemptian!ar Reg.MainL Elect. - =�(�Y�.2 a � � �SINGLE FAMILY � � � Temp.Power Pole&Appurtenanees 7� f. 5 "�� � HOME OWNER-BUILDER OECLA9ATION Sign with One Branch Circuit "� ° � �4�y�czi 1 hereby ailiim that I am exempt trom the Contractor s Lkense Law qtltlitional Sign&anch Circuics - --. . . .O t.L��H�I tor the following reason(Sec[ion 703 L5,Busines5 end Pmfessions Cotle): ❑ I,as owncr ol the property,will tlo the work antl the structure Misc.Conduits 8 Conductors . � - � - - � - � is not inte�Wed or offered for sale(Section 7044,Business Other(See Comp�ete Fee Schedulo)_ � and Prolessions Code). CONSTRUCTION LENDING AGENCY � - ' � I hereby allirm that there is a constmction lendirg agency for Ihe oerformance of the work to�which this permit is issuetl(Sec.3097, � pEqMiT FEE �"� (Sub-Total) .1�5 44 - � Civ.CJ. PLAN CHECKING FEE � - � � -� - � Lentler's Name �O 50 PERMIT ISSUING FEE . . . . . . Lendcr's Address � I certify that I liave read this application and s!ate[hat the abore TOTAL FEE 115.94 _ inlormation is wrrect.1 agree to comply with ull County ordmonces and State laws regulating EleMrical wiring.aM hereby autMrize � . . representatives of this County to enler upon the ubove•mentioned � property 6r inspection purposes. � , �j - � �SEE REVERSE FOH E%PLANATOHY LANGUAGE . . (/— �,atRre o t mmee Date � � ;_y ,..-,. , . .. ,. . : . ..:... . ... ... .....,... f . , . ,�. � � . - ., . � _ �. . - . .. � .... .:.� � . .. • ..� ' .. "; . _ , � i �� :;. .,�.��: .��- .. .: . �, ... .. � � i, . '�. r ' .-f.� ..:�. ' ' . ,. --� I , � � . . . . . . . � .. � . . _ � , � . _�:,,.. ...,i ,_._ ,.. ..., . ,. .i'�.. ... � ._. . . . .. � - . . _ ., . . ..__(_. .. ...: ....... 'APPROVALS_........._«_ DATE .�...�.I SIGNATSRES..-...._. -.(. ' _...-.-. .Y �._O�NNEEI'BUILbER DE.. . .� � ��.. __� ._.__ ..,.... �""' .__........ ,... ` .. , , . . . � _ . . . . ___ --- . :. CLARAtION:,�. i_ _ _ ___. � _ � � . 7EMP.POLVER PDLE � .. � - � �� � � I hereby aftirm tha[I�am exempi from the Conhactbr's Lice��se ., ..,.... . �-r � � . .. ... . . .. � , �-� . i - � .� - �� �� � � ���� �� ' � � . ,. law for;Jhr tollnv�in9 reason fSection 7037.5,Business<ind , . . _c.._ . _._. . . . . ,. UNO[RSLAB WORK � - � __. ._.__. - . . . - Frolessions Cotle):Arry city or counry which requiies a pem•,if � � _ , .. . __ � _ .. . . . . , ''�1�j ,to eonsWct'alter,ir,ipro4e.tlemolish.ai rePair any stn�c,ure p�ia - FOUGH CONDUIT � �� -'-- � ' ' � � • �� � ' � � -io!(s Rsuancq alsa requiies tne applicanf for such�perm(to,fi7�,�'� �� I � � r �, � . � � �signcd Statcment fha:he�s licenscd pursuent to tAe promsions V1IRING . � , � o/Ihe CanhaMa's Lkense Law(ChsA(er 9(commencing wifh !...--" �-�--��- --���-� . .FIXTlJRES�-- � � - �.._-.�..- �-- �. .."----- �-� �'.� -Section 70001 o�-0ivisiorr'3 ot the B:biricss�and.Protessions ': -i _-::— .._-. _- -_. �- - -. ; .. ._ _.._. . � ....--- . .. ; �' „^ P POl"JER'AUTHOFl12E0� � . CodeJ or lha+he�i..�exem f'�therelrom-and fhc Gisis��or n'Y� �� ��TILRY CO.N0T7F7ED-- �. � � ; alMgetl exemption.Any.vio7atrrn o/SecLon 7031.5 by ary I. ._._.. . __-_-- �NIO ES__. __-_. I'Y1lCY 01t�Y011�_.. .f . . ' .___-�_� �- : .� � o���tl,asho��er��uncYedo�e 1rsEwili tlo',the�v�ork.'aniLt,he F P Y . . . . .... , , . ,� . . ., , ., , ,, . .. . .. , , ; - . ,,.rucmre is not intended or ottaretl fer sslc .._..__._ ��. ,.- . . .. . , � ' „ .. . . . �. (Sec.7044,Husine.^,s antl%ofessiau Codc:�The`Canlrw..,r's' i . . _._. __.._.. _.._._ . ._ . ..'. ' .. , : � . i „�,, ., „, . . .,.,., . , �-���License Law'does not apFly Io en uv�mer ol propeny who buiids ;__.. _�'_ .. ..'_..'_ �._...- _._. ! '� . �.�� . . . � -.. . .. -or ir�anrs fhereon:�znd who tloes sueh wa•k himsNf prw'ro'ed . that such Inprovements arc rtot intcndcd o�oRcletl Por sala!(, . .,• � ... .. .� .• �,,.� ..�. . . � howevcr,fhe buildin or irt - . .. -:'.:�.. - _.. . _._._ .. ' . �. ___ . � : ',, � _ . �. . '_- � �. c� M�rovement is sold wlthin rnc Y��r ol � ,.... �., ��� � � . .,.�.- . .. ..�. . . __ . ._. ._ . .. . ....._ . -__. . , cwnplefron,ihe owner-builder wi➢Aa�e fhc 6iuden of pio�in�Ihat ....__. � _.......__...... . .._'__. .._ � . . _. _..__. . . ., , , . �, . � . � , he tliU nof bu0tl a lmprovd for Ihc pu+{�osc o�Sak.J�' ,'�� ; ��,� � �� ( , �. '. '. . �. . .. . , ' . _ . . , . ..-- ----.-.- _-'_ . . ..__ � ..- . „ ..-,...., � � . . . �� ...---. � .. . � ; � : �. . . . _... . .:-., .. .., .. .,. , . '� ; ._.. . , ,.. . � . - - � , i am exempt under Sec. . . . --__ .-__ . . _._ . . ._.; " � . . , � . . ..�'� � .. . � .___.B&P.C.tor-this rcason � ' . . .__ _.__.. .. .._. . . , . „ ,.. � . , ; ...Qate---- - . . , : , .. . , .. . . . ., � - -_ . , - -- .; � � � � . � . - , � _. I_i , Owner __ - � ' .. . . . - . � �. ., .. . . - ....-♦ _ --; � I _ _ j I L' _ _ _._.. __-- _ _ . .- - � ,. i • � r