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HomeMy WebLinkAbout0990A (5) r - - �� WOFKERS'COMPENSATIONOECLARATION �6A66a �o�e� qppLICATION FOR ELECTRICAL PERMIT � {� , I hereby a}firm that I have a certificate of consent to self insure, CE-eoeG �� or a certlficale of Workers'Compensation Insurance,or a certitied . COUNTY OF LOS ANGEIES 600 BUILDING AN�SAFETY ppy thereof(Sec.3600.Lab.C.) , Policy No. �00�7R9 '.�mpany -� STATF FTTnm FOR evruc�NT To F�u iu � � � �e � 24225'HRECKENRIDGE LOT 49 �� .❑ Certifietl copy is hereby furnished. EACH NO. FEE aOosEsS . New Residential Bldgs.&Pools � Certined'copy is ti�ed wtth the county bui�ding inspection 1&2-Famiry,Sq.Ft. 2636 S .0 — 5 LOCALITV DIAMOND BAR TR 42571 . depat�men[. ' , - MUlli-family Sq.Ft. — NEAREST , � e- t2•(�•��- � Residentiol Swimmin Pools � � - CF�OSS Sr. DR � Appiitant x' �� 11 FT F!`TRTI` I L'� � OwN[R OR ' FIRlANAME M.J. BROCK & SONS, INC. � CERTIFICATE OF EXEMPTION FROM WORKERS' . putle[s:Rec_L�ht_Sw.— � •` ��� � COMPENSATION INSURANCE- � - � � nDDaESS � Q (This section neetl not be compleletl N Ihe work Invdved by the First 20 peMnit is for one hundred dollare($700)or less.) . To[al No. Adtlitional CITY BREA 7e�.No. 529-8170 I cerlify ihal in the performance of ihe�Wofk 1or Which thi5 pefmii PLAN GH[CK is issued,I shall not emptoy any person in any manner so as to APPLICANT beeome subiect to the Workers'Compensation Laws. L'ghting FizNres First 20 �A�DRESS ^ r�. � � � ' -�� � � - Total No. Addilional � ' Appiicant CITY Tel.No. .�fICE TO APPLICANT: If,.after making this-Certificate o1 Fixed Appliances Not Over 1 HP pEaMiT Ezemption,you should 6emme subject to the Workers'Compensatmn . � Rarge_Heater_ D.W. _ pppuCpN7 E & D ELECTRIC I CN. provisions of Me Labor Cotle,you must forthwith compy with such Oven_Dryei_ W.M._ ADDRESS 319 lIC ARTHUR WAY 4i1 �provis�ons or this permit shall be deemed�evoked. . Top _FAU _ W.H._ C17V - Tel.No.� � � LICENSED CONTRACTORS DECLARATION Hood_Fan _ Other_ 1 hereby alfirm that I am licensed under provisions of Chapter 9 uCENSE oR ' (commencing with Section 7000�o(Division 3 of the Business and �isp. — Room Air Cond. — REG.NUnteEq 422589 � ��s=C-10 - Professions Code,and my license is in tull force and effect. D�STRICE No. FaoCESSED BY Power Apparatus 8 Large Appliances _ � Size 8 Type HP,KW,KVA,or KVAR � ,o(� -� � � License Number 42258� Lic Class C'-10 � � -� Up to 1 Incl.� � -- FINAL E &.D ELECTRIC I&�N.�•��- Over 1 to 10 Incl. DATE � yqLI�ATION � �Cantractor a e Over 10 to 50 Incl. O ❑ I am exempt under Sec. Over 50 to 100 Inc. BWAL 1- V B.BP.C.for this reason � Over 100 �y`; � � Servfces.Swbtl.,MCC&Paneiboards ► -� � - - � � Date: 0-200 Amp.lJnder 600 V � s�9�a���e 2oi-i000 amc.u��soo v '�'�'9��� � "- " � ' � � � Ovcr 1000 Amp.or Over 600 V � t�a � o �2 ❑ Exemp[ion for Reg.MainL EIecL � � � � - -- . . . . ._ . .�,,.f�' � SINGLE FAMILY - � Temp.Power Pole&Appurtenances � ° 1 1 5.9 4 HOME OVJNER-BUILOER OECLARATION S�gn with One Branch Circuit „ � � :,S'(:� I hereby alfirm Ihat I am exempt from the Contractor's Lfcensc Law ° lor the following mason(Section 7031.5,Business antl Protessions Additional Sgn Branch Circuits . , cod�l: G r,�4-b% ❑ I,as owncr of ihe properry,will do the work and the structure Misa Canduits 8 Conduc[ors � � � � - - is not intcrxletl or ofleretl for sale(Section 7044,Business Other(See Complete Fee Schedule)_ ► and Professions Codo�. � � �-� � � �� � - �� - - �� � CONSTRUCTION LENDING AGENCY � � � . .. , . I hereby affirm that Ihere is a construction lending agency for the perlormance ol the work tor which this permit is issued ISec.3097, . pERMIT FEE � � �ISub-Totall - 1�$ [�(� � - ' .. . - . Civ.CJ. � PLAN CHECKING FEE _ . . . . . . . _ _ . . . . Lender's Name _ PERMIT ISSUING FEE �.O SO LenUer's Address ' 1 certify that I have reatl this application and slate itiat the a6ove TOTAL FEE lj$.94 � intormation is correct.I agree to comply with all County orclinances � � � � - antl State I�ws regulating Electricai wiring,nnd hereby authorize representa Vb,es of this County to entcr upon the nbove•mentioned -� - � -� � -� - � � - � "� - -- -- - � ^rt pf inspection purposes. � SEE REVERSE FOR EXPLANATORY LANGUAGE � � � ����u`��- - - Si ture ot �r tee Date . - _ _ — - --.._._.. �, r• � - �� a� � � - ,. � . i=.. .. ._ ._ . . .... .. . � . � . . .. . � , , .. ' . .. , , , . . . . � � , . �. i .- � 0, . _. _. �. _ , . �! . . . , ., , - .__. ._ _ _... .___.._. ___.._... --'-•_.. .� _ . __ . --_ - --.. __. __,..,__ . �• .i .., :"; . , - _ iNS�ecTo�s . _ � --- �' 10W - DE , nPPaova�s � - �arE . -- NER BUILDER CLARATION �'SIGNATURE -� -- - ' . . . . ' �, ---._._ ... .....- ___ ,.. . ., -;-�� - - � ' � I hereby aflirm ihat I'am ezempt from thc�Conhactars License I��,� ., ;�'� .�' .TEMP.�PQ\NERPOLE` ..-. -� .[..i ._'. _, ':,,. : .� , , , i . . _____. -- .- - - _ . ----. �. . . .. . , . . La•a lor ihe followir�reason�fSecGan 7037.G. Ousiness aad � UNDCflSLAB WORK - - - -- - �--- --� �---� - '� ' ����� � �� � Prulessions Cotle):Any eity w cowry which rcWires a pemiit i ' ,ROUGN CONDUIT. -- ' - � ' � � �' : �to eor�Wct,after,i+rrprove,demolish,or repa+i,arry 51rocNre,prioi �• . '�'I ro'its is:umue;�a7so iequires Lhe applicant!er such pCrmit to file � WIRING � - �. . � � a signed st�lement ihal he is lrcensetl pursuant!o fl�e proNsions , .._ . _.__ _ __ , � � _ __ . ___(' . -. . .. � , o/Ne Conhactor s�L�ense Law(Ch y�ter 9(cornmencing with � ��._��, - FIHTURES., � � -- � -- - --' � ��Section Y000)ol-Oivisiar 3 ohfhe Busine.�and Prolessicns � , i .. - . _... . ._ _ _ ._ . __ -. : , . . ---`"-"""--'- " �-� " �-" -POWER�AIJTHORIZEO � �e!�o��fhat Ae�is��ezempt thcrelrwn and 4he b.ssis 1d.`fhe j , alleged exempfion. Any'violation ot Section 7031.5 by r,ny �-�--�---� ------- --� UTILITY CO.NOTIFIED . � �. a�ficanf for a�pelmit su6jecfs the.:pplicant to a eivi!peneM,y � �-.. .----�--------- --- FINAL----...-- -' /j�Y1LL'T'OK f'YOi2t . .', .- �� ' : o!not more than f`vc hundred dolLvs(5500J: , � __ ____ � � . � ❑I,as owner of the property will do lhe work and?he � . . � _. . ___-_. ._ _N�7ES ..---__—-. -._ ' � ,, . - � .,,, 1 .-- struc[ure is not intend�or olfered for sale. - -- � �i ' �i. ,.. . , ' , � . . � . . . y �(Sec.7044,�Business nntl P�ofessions Code: The ConVacxw�s i ..._..__._..._ _-_--_._______.._ f.._.. � . _ � : �,. i � � , � � � � , , � Llcensc Law tlocs rrot appfy to ao o�ma ot prqoerry who bu`!ds . .... , , . _ .. , , . � �' ���.. - , . ; ���� � '' � '�� --� ' � �- '��' - � � `� � 'or improves thcveen,and who does such v✓ak himseft prwitled , .___.-_ _.____ . . ._ .. _.. .._._ . ; ,, . that such Improvemen(s a,ro not in:ended or oRered!or sale.�lf, -,-,__:�'� - -!`�-_._ - , _ ' ._ � hrnveve,tF,e builC;ng a improvement�s soltl w+thin me yr.ar ol � . _-__._ ___ _ __ . . . ' comple!irn,�the owne�-bur'Cc�wil'ha�e the burdrn ot proving thaf '`�--''-'-'-'""'..".".."'--.-." -"" -..."._".. ..-"` ' ; '. hc d;d nof build or irnpiove/or!hc u '' � . . . . . . . . P�pOsc o!sale.J,. i �' i ' � 'f ' . . " . .. . . . . � : . � i , � , , .�..�.r ,. . i � , - - . � . '___ �- `. ' � ' r� -.., , . _.. _.... ..__.. __ . . . ' ,. . _ ._ . '�_' ' ,_. . � .� , . � ._ _ _ ..... __. ___ .._.__ :.'� ; .� �,. '�. . � -. _ . ___.:. . _ .. . ._ . . _ � :. . . r _. . . ._.. . . (:� . . _ . - 1.. . -- - - --,.. . .. � .,:]am exempt under Sec. _....�,. ,, �.' � . . . _ � �� . . , B 8�P.C.for�this reason - . . �...-i , . . . � --.. . ._._ . _ .._ _ . . . : . ... _ .._._ .,- --- - . �. _ � � : -Date- _ - � • �'�. . , Owmer � , . . . ._- � . . - ---� - -- � . , . , ; .. � � .. � , �-- - ---i--'. _ .. �� �. � � � . � .. . � , -- ---._-----..� . .. . - ---- .... _ ._ . � � . � ��,i ,. , '.... '_—___._-.--`-------- -----�------.. ._---..^___� .. .,. . . .�.��...�.__ � , i . ... ,.�.. . . . . `---.. ._ .._ . � , , , .,�� �i . _ ..----------- - . .. .. .. . . ... . . ._...___-_._. . ) ---.._ . � . , ,. .. ! � . ,I _ ` . �`� .. � ' ,