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HomeMy WebLinkAbout0965A (5) i WORKERS'COMPENSATION DECLARATION 76A863 ,o,e1 APPUCATION FOR ELECTRICAL PERM{T {� � I hereby affirm tha:I have a certificate of consent to self insure, CE-BOEG � or a certilicatc ot Workers'Compensa�ion Insurance,or a certitied COUNTY OF LOS ANGELES BUILD�NG AND SAFETY eopy thereof(Sec.3800.Lab.Q) 4�� Policy No.� 1�03�82 Comoany -STATE FUND Fon aaauc�rrr ro Fa�iN � � � � JOB , 24242 BRECKENRIDGE LOT 24 �QqCertifietl copy is here6y iurnished. New Residential Bldgs.8 Pools � EACH . NO. FEE /DORESS Certified copy is filed with the county 6uilding inspection �&Z-Family,Sq.FL ���7 S — $ LOCALITY DIAM013D BAR TR 42571 . ftlj'artme � - Multi-family Sq.Ft. — N[aqESi . Residential Swimming Poots CROSS 57. �itpare`�L'� "a Applicant E fi D ELECTRIC INC. aM�,°�`� M.J. BROCK & SONS INC, `� CERTIFIGATE OF EXEMPTION FROM WORKERS' Outlets:Rec_L'ght_Sw.— � MAiL � . COh1PENSATIONINSURANCE � � aoDFlESS 'This saction nced not be complelad if the work Invoivad 6y the. First 20 �, TotalNo. Additiowl CfTY BREA 7e�.No. g29_g170 rmit Is for one hundred tlollars(5700)or IessJ. I Certify ihat in Ihe perfofmanCe of the work fOf vihich this permit . . �AN CHECK is issued,I shall not emp!oy any person in any manner so as�o APPLICAM � became subject to the Workers'Compensation Laws.. Lightinr�Fixfures Firsl 20 � ADDRESS -� � � � � Total No. Additional ''��a � Applicant CITY Tel.No. i10E TO APPLICANT: If, olter makin this Certiticate of Fixed Appliances Not Over 1 HP PEHr,vi 9 aPPucar+r E & D ELECTRI CINC. Exemption,you should become sublect to the Workers'Compensation Range_Hcater�D.W. _ provisions of Ihe Labor Code,yo�must forlhwith comply with such Oven_Dryer_ W.M._ ADDRESS 319 AIC fF provisions or this pe�mit shall be tleemed re�okea. Top _FAU _W.H._ CITY UPLAND � rei.No. LICENSED CONTRAGTORS�ECLAFiATION tiood—Fan _o�ner_ 946-2131 I hereby affirm Ihat I am licensed under provisions of Chapter 9 . pisp. —Room Air Contl. _ ucENSE oa _ . pase. �(cOmmenCing wi[h Section 7000)Of Oivi5i0n 3 O(1he BUSinC55 and REG.NVMBER' '�l2�LSII9 - Proles5ion5 COde,and my IiCenSe is in fu�l fOrCe and eHeCt OISTRIC7 NO. PROCESSED BY Povmr Apparatus&Large Appliances /� 1 Size 8 Type HP,KW,KVA,or KVAR � (/ 0.lpy�e � License Number 422589 Lic.Class �-�0 � �� - -Up to 1 Incl. FINAL � - - �}-� Over 1 to 101nc1. �ATE ���% a Contractor E & D ELEC p��e����O T r VAl1DATYON Over 10 to 50 Incl. FI AL�n � ❑ I am exempt untler Sec. _ Over 50 to 700 Inc._ BY/� . _ . _ W Over 100 � 8.8P.C.for this reason - N • � Services,-Swbd.,MCC&PanelboarUs - ► � . - - - - - ^ � Date: 0-200 Amp.Under 600 V Signature �201-1000 Amp.Untler 600 V � -� � � � � � - - o�e�t0o0 Amp.or over 60o V `O 9�rJ A Exemption for Reg.Maint.Elect. �•/�'�� ' SINGLE FAMILY � � '� � Temp.Power Pole&Appurtenances �' ' � ' �2 HOME OWNER-BUILDER DECLARA710N Sign wi�h One 6ranch Cireuit � I • 1 3 2 5 8 1 nereby aflirm[hat 1 am exempt Imm ihe Contractor's License Law qtldilionat Sign Branch Circuits for Ihe followi reason(Section 7031.5,Business entl Prolessions � � � � � � � _- Cadcl: � o ¢ 1 J 2,�J a c� � � Misc_Conduits 8 Conductors . .. �a 2 4-a 7 I,as owner of the proPerty,will do the work antl the strocture Other(See Complete Fee Schetlule is not intended or offered for sale(Section 7044,8usiness 1— ► antl Professions CodeL � � � - � CONSTRUCTION LENDING AGENGY � � - - � . � �- I hereby aflirm that there is a construction lending ogency for the pertormance oi the v�ork for which this permit is issued(Sec.3097, � pERMIT FEE � (Sub-Totat) 122 �$ � � � - Civ.C.). � PIAN CHECKING FEE . . . . . . � . . . Lender'S Name ' � PERMIT ISSUING FEE LendeYs Address 1 certify that I have read this application and state that the abwe TOTAL FEE information is correct I agree to comply with all Counry ordinances - antl State laws regulaling Electrical wiring,and here6y authonze represenlatives ol this Counfy to enter upon the above-mentioned � � � � � � � � � � roper y�1o�inspeCtion purposes. � 1 _,,,,,�,� ry-j�� ,rj^^^� SEE REVERSE FOR EXPLANATORY LANGUAGE CA'Y)7 "-s 4> �i5 at re � i f e j�E Date ��- . , ,� , - , � ' � . ' , � . ... . . . ...r� . . . .. _%.. . . . � . .. „ . . , . � �. . ... ,. . ... .. I � . �. �... ..�. ..,, ,�� , ,� -. ..: .._ , , ., � i '. , ��' '-� � � .. �. -, ,,. . ..�, . . .., , . �..� .�. . . ., i:��r � ... . �....�'... . .. . . �, •. _..__�.' '"_ ___"""" .__ ,_._.,.�. ... __..._.__...-.��..._._. ...__ . ..... . .. .. " ' ._.._.... ..... ._ ... t . r��T :: ...f.- . ' ..� - --iNSPEc,i�R�s-. - �-'-_- - . '� ---... -�-.- .� 04YNER-BUILDER�ECLARATION ' ' ' ' APPROVALS ---DATE - , SIGnlAT RE i'_. .- -._" __ � , ' � � ;�� �• � TEtJR�POVJGR POLE �� � ,. - . �� i I hcreby affirm tha[I am exempt from the Contractor's License ; '" ":.. � : :�� .� � � ,. � . . � ---- ��-��=-'---�'-- --� �- - � � � � La�x for the tollowing�easoo-(Secfion 7031.5,Ausrness aird � � UtdDERSLAB IYORK ' -- :-� � ' � � '� �' pro/ession;Code):Am,�ciry or eounry which rcquims a pem�it __ . . .__ . ._ _. _ ... � . _—___ . . ..-'_ `___. . . r -� •� ROUGH CONDUIT., ---�"� "-�-"�i - -�� � � ' � " ' ` '.� �� '�°ea�sfmct a!(er,imp�o�e,demoh'sh,er rep.�i�arry s:�uctwq piw ',_____,. •� ...._�.,_��_�,_______.� .. . - . , �' ' .`folfs issua�ce.also mGurres(he ef-Y�lican(/w such Perm�t fo".e,^ � 4VIRMG ���- ' _ ___ � . _ , . , a sic�netl sta!ement th�t he is fice»setl pasuont to ihe prdvisions � � � �- � �FIXTURES� ,� - - � - �- - - -�- � . ar�e Cantroeror'S�Lkense Law(Ch.Aptei 9 fcommerrcing wi2Y _ _ . ,. ;�,_;� �� �'�' -'� � •�� � ' . .. � . Section'70001 0!Divtsipn 3 of the 6us��ncss and Pmlessiop�„ ��_' �-----' ""-'-"" '"'"- Pp19ER�AUTHORIZE�" , . : � ; Code) or tha!Ac is exem t�fhereiran and 16e 6asis for- � p .�c � - - U71LI7Y CO.NOTIFIED ' � a�lcged exemption. Any violat;qn ol Section 703 f,5�by�y i'_._'_.'______.__. . .__ . . � � � , , , �� ap;,lica�t)or a permit subjecfs Ihc.^.�plicant to a-civil A�?fty -•-�--- -- �-- FINhL�---� �-��- ; t1 rY011Y �� ' � � � � ; or not mae man five-nuntlred tlon�rs(350D): ' � � �� ' , _ _,___ _�.� � � i, ❑I,as o�+mer o1 the Oroperty will tlo ihe work,andlnn . _ ._ ._ . .. ..___.... _.NOTES_ .._ _.._. .. � � ---�siructure is aot intended or oi�ered for sale. 74 CY O .J. !�- � � �� � � . , ' , . � (5ec.7044,Business ane Prof2ssions bodc:' ihc Con!r,n,...s � , i __ . ._.__ . _ � . .- __ __.. ._... i .� . ...�,` � .�;'-. .� ,� � � ' � � w imp,roves thcreaq g�Y to w ovmer ot propertY n�ho builds �. ___ _. ' , -. .. �. .._ , License Law docs not 1 ... ._ - _ __ _ . � �� � ntl who does s��ch vrak him;elf povldetl � _ , . , . , fha!5ueh lmprovemen(s 2re npt'inf^nCetl or O�fCreU!of Safe.�lf, ._, '_-.-___.'_... ."_._...__.____ _-.._. _. _ .. . .- . ' hwievcr,the 6uilding a�imP�vemen(is sold wilhirt one ycar o/ � � - " � ' � eam tction,fhe o�✓ncr-buiidcr w,t7 have tne burden o! -. , P proving Ihat ....��._..._ . ._.,.__ ::._,_, . . , �. � �, � � ..:_-�^�� ������ �� ��� ���� ' . � � hc�did not build or impiove for thc pu�posc ol salcJ . �, .. . . . . c. . ;(� � �� ' . i �� , ,.. , . � . . \ �., - , , . . � �,.:; _.,; , . � . , ; .. . � �' � � � - - - - ��" -�� ��- -�' 1 am ezempt under Sec. ��� � - �� _ _ .. _ -,, �- ,, -,� -- � - '. _. , .�.... . �_ .. . -. . - ... . . - .--. . . . . � I .- _ . , ---B&P.C.for this reasan- ' . . � `----. -._----_ . . . ; � -. . . _. . .... .... . . i� � _.__.._- - _ . ----- - ----'�. . ' .. ., � .. .. .. _._._ . - .� . � r _ ._ � . - - . __._. ___..�... _ .. � , . . � - - � , ,. � I - Date- - - .... .-- .. _--- , . . � i . . . � � ._ ' . .. , . , i ' Owner .. . , �...� , j -- � � --- - - .. ... � � � j . . ..' .-. � � . �, � . . . . i,....., i ` ._. . '_-.'_'-_.._.._._ __.--- - - • .. � '- i / ,1 . � _� . -. - ' . � , ... ,I. . .. ,