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HomeMy WebLinkAbout0989A WORKERS'COMPENSATIONDECLARATION ]BA663 �018, QPPLICATION FOR ELECTRICAL PERMIT I hereby affirm that 1 ha�re a certificate ot consent to se��insure, CE-e08G or a cenir�cate ot Workers'Comvensatioo�nsurance,or a cerGred COUNTY OF LOS ANGELES 500 BUILDING AND SAfETY � �opy thereof(Sec.3800.Lab.C.) w�icy No. 1003782 �mpam STATE FIIND FOR APiM,ICAM TO FILL IN J� 24235 BRECKENRIDGE LTO 4 � � ' EACH NO. FEE ADDRE55 Certilietl copy is hereby turnished. . New i7esidential Bldgs.8 Pooi r] �CertR�ed copy is flied with the county building inspection 1 8 2-Famiry,Sp.Ft �291 � = S LOCAIJTY pIAMOND BAR TR �1 �c departmen�. Multi-family Sq.Ft. rieaaesr —��^��' E & D ELECTRIC ICN . Res�dentiai Swimmirg Pools o,R„NE oq oate AppllCant pIRMN0.ME M.J. BROCK & SONS INC. � � CERTIFlCATE OF EXEMPT�ON FROM WOFKERS' � putlets:Rec—lk3ht_Sw.— � ��A�� COMPENS0.TtONINSURANCE� � ADDRESS �•,�� First 20 �Thk secfbn neetl not be comp�efsd H lhe work imotved 6y lhe Total No. Atlditional C�N BREA Tel.No. 529�81� �. pe(mit ic fM o�e huMred dollare{5100)ot less.) � �t 1 certify tAa[in Ne peAormance ot the work for whiCh Ihis permit • �p�pp��M K � `is issuetl,i shall not employ am/person In aM man�r so as to ` -�:ecome wbjee!to Ihe Wwkers'Compensation l.aws. L'gh[ing FixWres First 20 � A��RESS - Additional �� `'� Applicant . Total No. CRY " Tel.No. ,�.�.:TICE TO APPLICANi; If, after making�this Cetlificate ol fixed Apptiances Not Over t HP PER�s�T E & D ELECTRZC INC. � �xemption,yrou should 6ecome subject to the Workors COmpCnSaliOtl . R�ngC_Heater_D.W._ APP���M j (ovisions ot fho labor Cotle,you must fw�hwiih comply with such Oven_Oryer_W.M._ ADDRESS 319 PfC ARTHi7R W � � prnisons or this Derrnit shall be deemed rewketl. , . ,Top� .—FAU _W.N._ � CITY UPLAND - Tel.No. 946-2131 f( LICENSED CON7RACTORS DECLARATION� . Hootl_Fan _Other_ � 1 here6y altirm that I am licensed under provisions of ChaOter�J UCENSE OR � ,(comme�cicg wiN SecNon 7000)ot Division 3 of lhe Business and p�sp' —�7oom Air CorW. _ Gass _ FEG.NUMBER 422589 " IProfessiDns Code,and my license is in full lorce antl eNBCi. Power AOParatus&L�Ipe App��aclCes oIS7RIGT NO. /� PPOCESSEo BY � � Size 8 Type HP,KW,KVA,or KVAR �V � p j i Lkense Number 422589 Lia Class G-14 Up to 1 Incl, fiNAL � U E & D ELEC �-i�'��� Ovc�1 to i01ncL QATE 'VAUDATION � ; �Contractor �ate O�er 70 to 501nci. � U � ❑ FWA � I am exempt untler Sec. Ovm 50 to 700 Ine. - 8Y {� � B d P.C.f o r t h i s r e a s o n Over 700 � � r ,�� -Services,Swbtl.,MCC 8 Panelboards , � Oate: 0-200 Amp.U�er 600 V , Sgnature 207-7000 Amp.Under 600 V � - - � ❑ � - � - � '� Ovc�1000 Amp,ar Over 600 V . . . . ' Ezemotion lor Reg.M�int.Eled. �� - �� SINGLE FAM;LV Temp.Power Pale 8 Appurtenances .. .. �C 9.�.O� � HOME OV,WlER-eU1LOEii�ECLARATION Sign with Onc Branch Ci�cuit r!m o o e o`� 1 nereby aifirm that 1 am exempt Irom the Contractoi s License Law p��tional Sgn Branch Gircuits - for lhe following reason(Section 7031.5,Business am1 Professions � o j Q 2�(� � Code): . e}L!2� (;_� Q 1,as owner of the Misa COntluits&Conductars ' property,will do ihe work antl the siruclure Other See Compieto fee Schetlu�e)_ is not inte�tled or offered for salo(Section 7044,Business ( ► - - - 0�G.2�"�'7 and Professians Code1. CONSTflUCT10N LENOING AGENCY � � �� � 1 here6y aflirm Ihat there is a consfmction lerding agency for ihe � performance ol me work for which this permit is issued lSea 3097, pERMrt FEE � � (Sub4otall� 131 �i � - �� � Civ,C.). ' � PIAN CHECKING FEE- � � - � lentler"s Name � PERMIT{SSUING FEE lO � � Le(Wefs Atldress I certily that I have read this application and state Ihal the ebove TOTAL FEE . . . information is correct.i agree to compiy with all Gwnty ordinances and State laws regulating Electrical wiring,antl hereby authorize , .. . , . . - representativzs of this County to enter upon the above-mentioned inspectian purpo4s�l 9EE REVERSE FOR EBPIANaTORV LAN6UAGE �� /)r�1b�/,a�I//L_ �—��`��— nate � � � �; ,. � , .� . . t .. _ �; ,�_ c . ���. , -_� r _,_ .._,.,._. � �- � ,__ .__ _ __—__ -- --. __.. ....__.__- --- --- - - _. . .. -- -...._______ — ; .�• - -�� � wSaEC70R'S � �. _.. ._` ��.'04YNER-BUILDEFi DECLARATION, � . , �.. ' , . APPROVALS --�DATE • E._ . _. . .. _. _ . . ... .'__. ._.. ��' � . . . . . ""SIGNASUF7 I „ . - ; �• --� TC�dP..PdNER POLE.��. � ��` ,. ���� ' '"' � Y tha[I a ekemp[from the Cantractors License I hercb aHirm :_ . _.�.'�_ . _ _. ._. - .. . �'. .. �' , Law fo�.Ne foilavrin�j reasan(Seelim 7031.5,.6usiness-and _ � � UNOERSLAB 4VORK ` !... ' .__._... .- ''__ ... ___' � HolcsSiax;Cotic/ Any Cify or eamfy whkh requims a permit �.. . ._.___ �.-._.._- ROUGH.CONDUIT �' ...- I.. - _.. � . , .� . ��, ! .-..� tocorrtvct�al�e{i�nPmve,Cemoli9i,wmPAirnny�sfa,<Nre.Pna ( _ ""''.��__ �__ ,_- . f ' tO'!LS-:SUJIIILC.8)50 ICQU CS hn fl�Jp(IG'Vil/OY�6(fCh PCRII f(o lil0 _. ..... � • / f i � b'JIF2iNG � „ , � a s�gnetl stAterrrertt fhot he is i�cen.^,cd pursUant to!he pb✓;sions ' ... _ .._-... _'.:�.__- rI�.U��$ __ ' ' _ , -, ( o!lhe Contrcteis Liccnse Lew(Chapter 9(commexiR9 wifh . '�-��-- - �' -�----� ' - t Seuron 700d1 o!Oivr^.:ian�3 ot.lhe eusincss any Pmtessims :'�` ...�-�"--'- "'`._.. POWER At1TNORtZED,. - , .. � ...... . ....- . .. , ...._. .-. � �" i COdeJ or�fhaf�c�is cxcrttpf tlierelran'and the ba5is lonlhe � � ; , . . � !����a�feged exempfion.Any viafation ot Sec!!on 7031.6 by aay 1 �--- ------- ---- - ---UTILITY-CO NOTIPIeD �� ' � . . . � ���pli�n!fa a pemtit subjeets Ne�appliem�t Io a crNl pen�lty � ,.� , ... ._ .. ._ .__.�._-.FlNAL.._ _ _.. )_'1lICY GI7 1'YO)Il .- . -... �.. . a1 r'ot mwe man fvc huntlmd dof:ars(55001: • - ; �� , - I '' ' _ . . ; Q i as ovmer ot the propeAy wdI do the xrork,Ilndxi � NOTES __. ' ' C. --- ------- --._.. ... .. ---. j j �. , .� � - strudu�e is not in!ended or otfered lor sale. . _. , . �„� � ' .. , � � . . .. � .. (Sec.7040�Busu�s vW Prola:sons Codc:-The Can:ruc..�� . . '. '. _"..' . ! i .. , .. , ., . , � , � - ., � " License Cmv Oces not nppJy fo an am�r ol DrcPtrty who buJtls i ��_- .�i' � .:':., . . , . . . ; ` � �. � --� �`' -�� - -�� � ' � �o�i+nprcwres tficveon,nnd who dees such wwk h;mse/f provia�d� ._ .� ._. _.._ .. __... _ .. .. ' i , . _ , . . _... ., � � . ftiat such lmprovemcnfs zm nof irrlended'a Mler�d fw snlc 71,�, +._ _. ._._.__. ._._... ._... _._.-_. .. ... ; ' ;. __ . . . ._.. ' ��.� � hrnvevc'r,�fRe0u77J�iigcvlmpioJementissoltlwithinmeyearol� , , ._ , ... �'.'. . .._ _� _____... _.._ . .... � � �corrrple!ion;fhe a�ner-Cur,'der iro�d!h,1vc tRc burdcn of pra�irg th�1 � . .'..-' . ',-� '�'-".. ._.�. . ..""' � .he tlitl no1 buiM o�Gry roee for�Ghe P��e o!sa1c.) ' � ' � ,f'. �t^% �{ . '. � . . � . . . . � _ � I ,. . � , . . . . . . � � _ _' .. �- __.. _ . .' _' .. _. . , � �-;i . . .,-�"'�, , I � . � '_._ __._.'_ ' _.__ � . __. . .. __._ . , . � � l��arri Cxempt under Sec. , , .� . ...__ _ ...._ .. � . . .., _.. _ , ;i �. . ; ._. ; _ .� . , . � � - B.€P.G.tor this reason '� �• ' �' i'. _. _'"___". .._.. � . � '..._ . j . ' . �, � i �. . . � . ., . . . .. .. � '....... ' :'i . .� .:� : - _. ""_ " . .. , _....._._ . .._ . _...__. �I ..` __ __ _. '. ": : . ��._. . , . . . . ` '""__'��tC"__' '".'_' .._.... .__ ..� , I � , Owner . _. � . . . . - `-�'. .. . . . .. _. . __.._. .. _.----- �_. _-. . .. .._j � �. . � , - , . .. . � . . . . � �: .,, . .. . . , � _. .._._. , . , . ,. , j . � . _ .. . , . i - _ __ � , ; __ --- _ . _ _ _ . � � _ . , ____ —; — , � . _� ;, � ,