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HomeMy WebLinkAbout0964A (5) ,- - ---__.___ _, f ___ _.� ,�� WORKERS'COMPENSATION DECLARATION 76n663 iOBi � I hereby affirm that I have a certifiCate of consent to self inSufB, LE606G APPLICATION FOR ELECTRICAL PERMIT or a cenificate ot workers'Compensalion Insurance,or a certified COUNTY OF LOS ANGELES 600 BUILDING ANO SAFETY � copy thcreofi�63���b'°'� STATE FUND Policy No: Company Fon.vnucn�rr ro F�u�N � � a�oRess 24234 BRECKENRIDGE LOT 23 ❑ Certi(�ed copy is hereby fumished. : .,. . . New Resitlentiat Bldgs.8 Pools EACH NO. FEE � -� Certified copy is filetl with ihe county builtling inspeclion 1 8 2•Family,Sq.Ft. ���g g — S LOCALITY DIAMOfiD BAR TR 42571 � ' artm t. . �� � Multi-Family Sq.Ft. NtAAEST ��j E & D ELECTRTC INC. Residentia�Swimming Poo�s crtoss Sr. .,^,Date��Applic�nt °'r"E�toR M.J. BROCK & SONS�INC. , � FIRM NqME � '� CEFTIFICATE OF EXEMPTION FROM WORKERS' OWlets:Rec_L'ght_Sw,— - � � MaiL � COMPENSATION INSURANCE � . � n➢DRESS P.O. BOX 3SO �This sectbn nesd not be completad if the work fnrolved by the First 20 ���rmit ie for w�e hundred dollaro(5100)or teas.) , Total No. Adtlitional - CITY . Tel.No. S29—HZ�O I certify that in iho perfo�mance of the work for which this permit _ A��Cr�ECK � is issued,I shall not employ any person in any manner so as to � A��� become wbject to�he Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS � - � � � � � Total No. Additional ��� Applicant CITY Tel.No. � .iICE TO APPLICANT: If, after making this Certificate of Fixrd Appliances Not Ovcr 1 HP FERMIT Exemption,you sFroutd become su6ject to the Workers Compensation Range_Healer_O.W. _ �����'�T E & D ELECTRI C INC. provisions of the Labor Gode,you must Forthwith comply with such Oven_Dryer_6V.M.` ADDRESS 319 PIC ARTHUR WAY�E 1 provisions or this permit shall be deemed revoketl. .Top� _FAU. _ W.H._ � qTY UPLAND 7e1.No.g46-2131 LICENSED CONTRACTORS DECLARATION Hood_Fan _Olher_ I herepy eflifm that I am i�censed undef OfoYi5i0n5 Of Chaptff 9 UCENSEOR (commencing with Section 70001 of Division 3 of.the Business and Disp. —Room Ai�CoM. _ REG.NUMBER c�ass. _ Professions Code,end my license is in full force and effeCt. . DISTRICT NO. MiOCESSED BY � Power Apparatus 8 Large Appliances . . . Size 8 Type HP,KW,KVA,or KVAR �q�O Q � License Nurnber 422589 Lic.Class C-10 - Up to 1 IncL � fINAL E & D ELEC �—� --C�{- Over 1 to 10 Incl. DATE f.�_Zr�7 0 -Conlrector Date VALIOATION Over 70 l0 50 Incl. FINAL - �"' ❑ I nm exempt under Sec. Over 50 to 100�nc. BY ��. . . W 6.&P.C.for ihis reason Over 100 N � � Date:� Services,Swbd.,MCC 6 Panelboards ► � � - � Z 0-200 Amp.Under 600 V Signature 201-10D0 Amp.Under 600 V � � �� � ���6.�:55 ❑ . . - . . . . . - .. .Over 1000 AmP.or Over 600 V ._ . . .. . O��'���� Exemption for Reg.Maint.Elect � � x� '�.�� SINGLE FAMILY � - Temp.Povmr Pole 8 Appurtenances . . . . . . HOME OLVNER-BUILDER OECLAR4TION Sign with One Branch Circuit t nereby affirm that I am ezempt from�he Contrada's Licenso Lavi pdditional SiBn Branch Circuits � for!he following reason(Section 7031.5,Business and Prolessionc ' �- � � - � � � - - Code): ❑ 1,as owner ot Ihe property,will do lhe work and ihe struciuro Misd Conduits&CoMuctors - - - �� � � �� - - � � is not intended or offered for sale(Section 7044,Businesc Other(See Complete Fee Schedule)_ ► . and Prolessions Cotlel. � CONSTRUCTION LENDING AGENCY - - I hereby alfirm lhat there Is a conslrudbn lending agency for lhc performance of the work for which this permit is issued(Sec.3097, - pERM17 FEE - " � (Sub Totap Civ.GI. � PLRN CHECKING FEE - �- � - . - � Lentler's Name PERMIT ISSUING FEE - -� - � � ZO SO � --- -- -�� Lend�:r's Address I eertify that 1 have reatl Ihis application antl sWte that ihe"nbove - TOTAL FEE . . . 11$.94 . �- . - , - , � Information i5 CorreCt.I agme to Comply wilh ell CDUnty ortlinance5 � and State laws re6ulating Electrical wiring, and hereby authorize _ _ _ . . . .. . . _ . , feDreSentative5 of thi5 County to enter upon the above-mentionetl propeft �or inspection purposes. /,����� �,� SEE REVERSE FOR EXPLANATORY LANGUAGE � a[ure of r� ee Date . : : . ,. . .... .r. .. ,. . r• .. ,. . �..-�. ,. . . ., � �� , . � . � . .,, .. .. i .... ... , , -'..'. .�:- .. .- , �• . . ! '.�.„, , . -.t . . � . .. .... ... I� . . . . . ., ... .. ' .. . � . .. � i , . . , . � I r , . �.. .. .... .- �I�.:^ ,- ... , . .. . .. , . . i � � . .4.:. . .. _ .. .. . .. ... .. . . .... . - .. .. . . ... . � . � ,.., . ._....__...�_._..�.�._ .__....._.�.____._.. . �..__._._.._. ......._____...._ ..._...._ .._ ......__.__ .. ._. , . . -�__.._.._.. _ .._ , :.�... . . ;� I ;,, .; , A?PROVALS oarE____ ._�siGrEiAiu°E - -- _ _ i _. .'._. . ----OWNER-BUILDER DECLARATION.. , - � i._. ��� c� %�_' :__� ��TEMP.POVlER POLE �� . . ,.-__.,_ �� ., . .. . . .-.,. _ . �.., � I hereb a„irm fhat I�a eexem t Irom t7031n�zc�r'�Lice�is „., Y P e � --- .__ - . -� •� � ! Law or,t c oliowinc�r aso (Sccic� . , si ess-and , UN�ERSlAB 4VORK . �. .,. ___. " �.... ._.._).__ ..___ . ." . �- � : �. Rv/essions Cotlel:Any ctry o'ceuntY whrch�equiies.a Permit ! -._..__ '_ .._._._ . � .�� .....�� " �FOUGH GONDVIT� . � . . ...-_. .'.. _. ...___.i . ...- . � � �� . :,i ,`to carshvct�alfc�,rmprove,Uemolish,o�repa�r any stiucture prror , � � � � ' � �-��-fo-lts Issuaoe0.�also requires fhe aAP��canl7w sueh permrt to f'--4�, ._ ...__-_____. . . .__ _ .. .__�. . __ # ,-. VJIR WG . S 7 , ' _ . .�_ . .i.. a siryied stalement fhai he is lice�sed pursuant to the prov�srons � ; __ .__.-__ _._..____.__� .__ . .. � ���-.. � � : ,,, � � � : 0/fhe Cwtracfa's License Lew�(Chople�9�(commencing wiih _,. ,� , � FIMURES-� �--�� -� - �---�- - - --� � � -��t�;.Section�7000)ot Divisrrn 3�ot�me Business.and�Pro/ess!w:s' `'�� �� ��--�-�-- -- � -POVlER�AUTHORIZED... . . . _.. _ . -. .--. . � � � -.- .. .� �. � � .; Cotlel or that hc is exemptYherefrom ancl fhe��h�srs lor� .�'� i----- ----�-�-- �-��-�--�-�-UTILJTV CO.�NOTIFIED� � � � ' � '�� a!legetl ezemption. Any violatio» 01 Sec!ion 703f.5 by arvy ' ' ' - �,pplicanf lor a permii sv6/ects Ihe eppficanf'to a civil penafty ; _.__.. .__._. _____ _.___ .FlNAL -__ ._..-.[;'y�jgY0111'YO/71 ...��. .--... .� ,� :�., �,��. �� i olnotmorclhnn(ivehundretltloqar5f5500/: . „ � ' ___ �:OTES _ � � � � � - ���-- - �`�� ' � ❑I,as owner o1 ihe property wiil tlo ihc wark,antl thr. �---------� - �----- �- � � ' -- . � ... ..stmcture is not intendetl or oflared br sala_. ^' ' � . .� ..,,:. � . � . , . . � �. . ,, ... � y � �,:, t.�, :�. �. ��, �� �. � � •� _.. ' ,i _. ._ �.� �, i ' . ' Con6a� � (Sec �044,�6usiness antl Piolessions Coda�Die� � s ' Licn�e L�v doe^rwt a �to en awner of prcperty who iilds ._.�_ . .._ �._ . _- � - . �. .__ .. . �� i �. � hovrever,h hc b�d����o 1mP'�emcn2a�work himse,7 provided ,-,. .. ., w oltcred fw ssfc.1(, �._.. ._ . .___._ � , � , . . � ....� . ._. ...._. ._ . . . _-- . � ' �canPlclion,the o�vner-buffder wrll have the burdm'cf proNng Ghaf � ...,.._ ....__._ . .. ...._...,. _.._'_.. _.. . . ... -�� � � I � �hc tlitl not build or Irnprove for Ihe purposc ol saleJ � -. '.'(. �;.i•l _I , j � , � , , _ - _ _ _-- - - �_: : � '--y . n -� . . . - .,. , , -. �. ... .---_. _ ._�--- .. _._ .. . � -- � �- � ----- -- .. _. � '�� � ' � • �_1 am-exempt�untler Sec. - �--� ------- .. .. _.. � , .. , , ... - - � . . ��i ; , ,� �. �... ...----- --�-- - - '� � . . _-88P.C_for.thisreason--�- ��- :� - - - . __ s f-. , , . �. .. . .. . . . - , . � �. �. � � ..��.�� � .— -. _ ._... . ..... . . . . ..---... --- - - - : . . . . � ��, . . �- . � „ ? Date- - � � � i._� � ' Ovmer - . . , ,. , � � -, '_. ... i � �: . , . , �. , ,.. �. . _ ���:�. ., . , ___ _---�----�--�- - .. .,.,., . , .. . , �..-i �--- �--- -._ . _.. ._. � . ,...� ��„�.:�. . . .�' ;- .�, � . �, , .,-. . .. I _ - -- � ;; . , , ,--:.__ . __ _ __ ---- --- _ �� � �------i � � . � _ ' . .. ,. � � _ . � �i�i� ._.... _. . .� . . . . .. .,.. �. ,. . � � �� � - � � � � ,� .., , � i,. . _. _._ : _. - -- --._. . _ .__._ _._... _ .. . -;�- : . _ ... _ . _. _�... . . � �- ` ,. -