Loading...
HomeMy WebLinkAbout0963A WORKERS'COMPENSATION DECLAFATION 76A663 1oJe7 � , �E.0o6� APPUCATtON FOR ELECTRICAL PERMIT 1 hereby alfirm Ihat I have a certificate ol consent to seli insure, - or a ce:bficate of Workers'Compensa�ion Insurance,or p certitied COUNTY OF LO5 ANGELES 5QQ BUILDING AND SAFETY cOpy thereof(Sec.3800,Lab.C.) Policy No.' 1003782 �mpany STATE FITND FOR APPLICANT TO FILL IN JOB 24226 BRECKENRIDGE LOT 22 .❑ Certitied copy is hereby fumished . New Residential B7dgs.&Pools EACH NQ FEE AD�RE55 i&2•Fami�y,sa.Ft. 3291 5.04 — S 131 64 LOCALffY DIAMOND BAR TR 4I571 ��n Cerlitiea copy is filed with the counry building inspection _ NeaaesT . iY�� tle artment. � Multi•family Sq.Ff. �_��`�-- E & D ELECTRICICN• CROS55T. ��-y„`Date Applicant ResidentialSwimmin9Pools �RMNA�UE T1.,]. SROCK & SONS,INC. � CERTIFICATE OF EXEMPTION FROM WORKERS' . putlets:Rec—Ligh[_Sw.— � � �'°'t�� P.O. BOX 3S� COMPENSATIONINSl1RANCE - � �� � � ADPaEsS � Thia sectlon neetl not be comWotW If 1he wo�k Involved b the Fiist 20 � Y Total No. Additional c�Tv BREA 7e�.No.529-8170 �M.�rrrdt is for one hundrad dollars($100)or less.) . . I Certify Ihat in the pelformonce Of fho woik IOr which this permit �p����K - �- is Issucd,I shall not emplvy arry Person In any manner so as lo become subject to the Workers'.Compensation Laws. L'ghting Fixtures - First 20 � A�DRESS �-- " � - Addilional � � � Total No. CITY � Tel,No. . _,_ Appl�cant Fixed Appliances Not Ove�1 HP .f�GE N APPLICAfJT: If, after making tnis Certi�icare ot PEttMi7 E & D ELECTRIC INC. � Exemption,you shou�d become subject to Ihe Woikers'Compensation Range_Heater_ �.W. _ naPLaCnNT provislons of the Labor Cotle,you must farthvritn comply with such Oven_D�yer_ W.M._ ADORESS 319 P(C ARTHUR Td provisions or ihis permit shall be tleemed rewked. �. Top �_FAU _W.H._. . � CITY UPALND Te�.r�o.946-2131 UCENSED CONTRAC70RS PECLARATIDN - Haod�Fan __O[her__ � I hefe6y affirrr�that I am licen5etl undCr proViSions Of Ghapte�9 Disp. —RoDm Air CAntl. _ LICENSE OR �gg (commencing wilh Seclion�7000J ol Oivision 3 of Ihe BusinesS 9ntl REG.NUMBEF 422589 —1 Pfo}e5sion5 CAde,�nd rtry IiCenSe i5 in tull IofCB 2ntl et}eCt � ppyyef Appalatus&Ltlrge ApplianCes DISTRI�i NO. PROCESSE�BY Size&TypeHP,KW.KVA,orKUAR - . 1�lalon�p � License N�mber 4225$9 Lic.CIaSs �m—�� � Up to t I�wl. � - FINAL -� � E & D ELEC W—'}�`� - o�r t to to�ncf. oAYE �IM1/ � �qLIDATION 0 'Cfjntraclor 'Oate pver 10 to SO lncl. ❑ A� � U _ I am exemp[uneer Sec. Over 50 to 100 Inc. gy � 6.6P.C.for this reason Over 700 " - Services,Swbd..MCC&Panclbaards� � , - � � - - � y � - Date:-� 0-200 Amp.Untler 600 V ""' Signature � 201•1000 Amp.Undcr 600 V - - - - - ' �- � � � - Over 1000 Amp.or�Ovcr 600 V � Exemption for Re9�Maint Elect. /�� � � SINGLE FAMILY � � � Temp.Power Pole 8 Appurtenances :'0 9�z 3 R `�'�" HOME OWNER-BUILAER DECLAR4TION Sign with One Branch Circuit tr o�4 L� I � 1 nereby aflirm that I am ezempt from ihe Concractor's License Law pddilional Sign&anch Gircuits . _. . . . . _ for ihe following reason ISection 703 L5,9usiness and Professions (�2 i� Cotle): - p Q�Ll�-� � Misa Gonduits 8 Gontluctors - - � � � 1,as owner oi the proparty,wilt do the work and the structure i�no[intendetl or offered tor sata(Section 7044,Business C7thcr(See Complcte Fee Schetlule)_ and Professions Lode}. . � � � `'� CONSTRUCTION LENDING AGENCY � � �- � I hereby affirm that�here is a Gonstruction lending agency lor iho performance of the work for which this permit is issuetl(Sec.3097, pERM1T FEE � - -� (Sub-Total) � ]_31 6(y - - �� - Civ.C.). �. PLAN CHECKING FEE . - .. - - - - �- � Lendei's Namc � PERMIT ISSUING FEE . .. .. �-O SO _ _ _ . Lender's Atltl�ess 1 certify Ihat 1 have read this application and state ihat the ubove . TOTAL FEE 14Z.],4 . , _ � _ , . , inlormation is wrrect.I agree to comply with all Cwnty ordinances and S�ate laws regulating Electrical wiring,and�ereby authorize - _, repre5entative5 oi this County lo Bnter upon the abwe-meniioned . er inspec[ion purposes. , . ._SEE REVERSE FOR EXPLANATORY LANGUAGE . . __.. .. . . . 1 �'2 �-1�'-��- ,yS�ignaturo o1 � e Date - }.� �. . . �=1�`.� . [, .��� �-� , :;7� ._. .�.�,. ..� � �, �.. � . � _. ,.._ . . . , ,. , 1 ....._. . __..._ .. ..-- _—_. __...._. .---..._... .. ., _..�_._ ___._ ._.. .._._.... . . .__. . _ . .. . , _ ' �� � '� ����� �� "'� 'APPROVALS �_ V� -'DATE. IflSPECtOR�S --_._'- .. - ;, -.--_. .� _._O�"lNER-BUILDER�EG`CAFiATION ' .'t �� i'� -i SiGNA7URE --�-� - - �- � -__.._ ___�_.___.. _. _ . _ . _ � -_. � " - � -�--�- -�-� ' '� �� " � '� ' I hemby aflirm that 1 am cxempt from lhc Contractor's Liccnsc � _ . ,.. _ • TEMP.�POI"fER POLE � ' .�. �.' i .i ., ...� � .. . � � '�-�--� -�--�`-' -�- -'-- ' � ' ' � - - - � � � � � -Law for Ihe followin�reasan(Section 703f.5,6usrness aorf � �� UNDERSLAB WORK - -.-.-. - ...._ _ .__ _.!�_ _____ _._. � , '� � Ro�cssions CodeJ:Any ciry q county which reGuires.a peimit � __�.. _______ . -__.. - - , , '� ���. to eon;bud,�al�er,iirp�rove,dcjmolislr,.or repairanY strucfum,pria ' .. ., ., �ROUGHCONDUIT.,� � -..i .__ _.. . _._ _. . . . . ! .,. '-' ' � -"-lo�its issur+nce,also rcquires thc a,ontrc�nt fo/sucA permtl te;�.,:`� .__._ . _ '.. ._: '� � _-_� , � �, :"': 4NRiNG,i,,� �� _!�� '� - -, ' a signed ah!ement 1h t h�is/icenseU pursvsnE to Ihe piovis'ons . .- .__ .. . . � ' .�- � .Sectio���700D)ol Division 3 of thapter 9(commencine�w�N � � ._ .. FIXTURES� .. --�_._ � ..-�. -. � ' . .; ,;: ho @+sinen antl Prol��ssbns . �.-I��- �-- �� �. ._-....". PO;VER-AUTHOR)ZED . -��-- -�- - .. -..---' ' � oCode)o�th�fhe'is�erempf3there!rom avd the hsis lo�-"�� ����-��-� ��----�-� -�-�--�-�--� �UTILITY CO.NOTIFIED �- �, � I � � i " -��al7eged ezemption. Any viofnfion of Section 7031.5�6y arry . . . . � apPlieant Ior'a perrnit sutjeets the.^.pPlicpnt fo a�civil pena,Ry ,..---.--. .- -� - - �---- FINAL--. . . ;(�f1tCY Ott/'YO1tL . '' � •�. �:,..� -� ' of not mae inan fivc hundred do1lars(5500 J: � . . � ... � __NorES.._ _.. .'. I I � '. -�� ---�-- � �� ' ❑I,as oimer of the Aroperly will do the work.andl�ie � -— ---- - ---- � - is not intended or olfered for saie - ,. -,,. .... . � , . �... ,' . .. . . . . .. . .structure. . � . -._._ —' � , . � -. ������.' � � �� , �' i -(Sec:7044,'Qusinc:s and�Ro/essrons Codcr�7he Con!rx._s ' __ .... i , ___:� � :. . . . _ , . � ,,. L�censc Law docs not aFA�'y ro an a:�ncr of prtperly who Guilds , � .".. . ,. � ,. . �''I; . .. ' �� ..� i -.... . . - � -. ' �� ."�'-or�imProves ihercon.,nd Who�does 5ueh v;ork him;cl(Frcvldetl �-_- _- ___ _ :_. . �. . . . ..._ _ . � , ,, , ,„, .. , fha!such improvcmrnfs am not intcnticd w o«crcd tcr satc.�tl, �.:.. � .- "_'..�.._...V�_-.�_. _...,.,. �_. �,. � . �..,r ,. �.,.. . . hp.dd not buifd o��rove/or�ihe pur,�osc of sale.J � o/ ! --- F howc.e{the bu9dm a improvement is sold w+thin one ar . e npl t on Ihc amc buddw a fl ha�e[he bu d ot proving ihat ..._ . �. . .� , . ; � . . ,. . �. � � ' . .. . / i i . � � - . . , ,,.. � � 1 -- - -- - . � :: ; _.: :. � - _ '-- _ , _ __ _ - _ _ .,. ...�,. � ; `, . �� ��. ��� __. : j� ;�1 am ezempt under Sea .._.- - —. ,. __._- ., � -� --- � --- '--'- --.. ,--. _.._. -_ �� � . _ - . . ' - ---- � ._-i - (-� i� . ..... ..._. .. . . . , . . . r..; . .__ � •.... ` � " � � . � . -� -B&P.C.-for-this reason . . . � -- �. - ' � � � - ... . _ . ... ._ -- - . _'-"'_-- _--. - � ' .,. . .,. .,__.. . . ._._._ . _ . . . � � � _! t --_ ._._. ___. .___ �. ,- ,.. , .. .. . ' �. '__,, _J , : . . ,.. ! _�_.___ . . . _. , _ .. ..- --'-- �. .. _ . � - i . . . ._ _.Date - -� - -- --.... _.. .. . ... . , . . . . . . ,. . .. � i't , � � . . . ,, � . .._. � � ,.. � Owner _ r . ....,. . . . � . . . �- : , _ ... .__ � � ,., .... � . �i . , ; .. _. � ; � ,. . .. . . , ., ( � . . . . . . ._ �. ..._ ...---� -'� - .- --- -.._. .----- .__ __._ ..__; � . � i _ �.___.--_.__ � . . --- - � . ,. . __ ._ . . - - -- --._ . _ . � .� �' .. � � i . .. � � . . . � - . . . _ .. ..... _ .. .. ___.. . . _ , - � >,