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HomeMy WebLinkAbout0968A (5) M WORKERS'COMPENSATIONDEGLAFATION 76A663 ���B7 APPLICATION FOR ELECTRICAL PERMIT � � I hereby,atfirm that I have a eertiticate o(eonsent to seli insure, cE-aosc � �` or a ce�tiFicate ot Workers'Compensation Insuiance,or a ccrtitied COUNTY OF LOS ANGELES BUILDING AND SAFETY copy thereot(Sec.3800.Lab.CJ . � Po�icy No. 1Q03782 �mpa� STATE FUND FOF APP�ICANT Tp flLl MI ' J08 , nooaess 24260 BRECKENRIDGE �.OT 27 .❑ Certifietl copy is hereby furnished. New Residential 01dgs.&Pools F�1CH No. FEe � DIAMOND BAR TR 42571 1$2-Famity,Sq.R. ���� g -- S IOCALITY C2rlified Copy i5 filCd with the COunty building inSDectlon NEnREST '�}', pert gM^ � � � Multi-family Sq.FL CflOSS 57 � . �_� �� Residenlial Swimming Pools .._ /���e � Moiicant E & P ELECTRIC INC � . �i°awiErRun°�R.�pf J RROCK & SONS INC. CERTIFICATE OF ExEMPTION FROM WORKERS' putlets:Rec—Light_Sw.^ �� �'�'�' P,O. BOX 3SO COMPENSA7ION INSURANCE . � � A�DRESS (TMis sectbn need not be complated H the work Inro7red by lhe First 20 pecmH la for one bundred tlollere(5100)w bss.) 7ota1 No. Atlditional ciTv BREA �Tei.No. 529-8170 1 oerfily lhat in�he performance oF the work for vfiiCh ihis permit _ . PLAN CHECK � is is9�led,I sh�ll not employ any peBon in Finy manner 50 85 t0 AP��M become subject to the VJorkers'Compensation Lavrs. Lighting Fixtures First 20 A�DRESS -� -� !� . Additional � _ Tolai No. CRY Tel.No. , � � Applicant � � Fixetl Appiiances Not Over 1 HP pEfin�vT ' ..ifICE 70 APPLICANT: If, alter making this Certificate ot qpW�CANi E &-D ELECTRIC INC. Exemption,you 9hould 6ecome subjCct[o the Workers'Compensation Rangc_Healer D.W. _ provisions ot Iho Labor Code,yuu must forihwith comply wilh such Oven,�ryer�_W.M._ AD�RESS 319 liC ARTHIJR SdAY �Fl pmvisions or ihis permit shall 6c deemed rovoketl. . Top _ FAU __W.H._ �-- CITY � UPLAND Te����9�J6�Z1.31 � - LIGENSED CONTRACTORS DECLARATION Hood— Fan _Olhcr_ I hereby allirm that.l am licensetl uncler provisions o{ChaD�e*9 uGENSE OR (commencing with Section 7000)of DiviSiOn 3 of the Business and 'Disp. _Room Air Contl. _ ' REG.NUMBER - Class _ Professioru Cotle,and rtry ticense is in(uli force and effect. Po��A �IS7RiG7 NO. P(iOCESSED BY pparatus d Lar9e Applianco5– ` yy� �� Size&Type HP,KW,KVA,or KVAR � } O 1��a f� � License Number 422589 Lic.C,l.a�s7s � � �� -- Up to 1 IncL FINAL � � �� �y1,�� Over 1 to 101nc1, �AT� !��(� .. VALIDATION � Comrector E &D F.LF.0 Oate� Over 10 to 50 Incl. � � FINAL .._ . , . . V 1 am exempt untler Scc. Over 50 to 100 Inc. - gy . W- 8.&P.C.for this reason Ovcr 1D0 � �� N . . . . _ Services,Swbd.,MCC fl Panelboartls � -�- � � � � � �- � - �� " � Z -Dolc- 0-200 Amp.Under 600 V , SlgnaNre 207-1000 Amp.Under 600 V � . � � -� � `�g�8 A. � ��,�-�- � � � � � � - Over 1000 Amp,or Over 600 V � _ �T� � � � �2 ^ Exemption for Reg.Maint.Ekct. . . j ,i 7 5.9[G � SINGLE FAMItY � � � Temp.Power Pote E Appurtenances _ . .. ' . . HOME OWNER-BUILDER OECLARA710N Sign with Or.e Branch C'vcuit I hcreby affirm that I am exempt from ihe Contracta's License Law ' o e���Q 1�� for ihe following reason ISection 7031.5,Business and Rolessions Atltlitiona{Sign Bianch Circuits � Q�� g Caae): � ❑ l as owner of the property,will do Ihe work and the structure Misc.Conduits 8 Corxiuctors � � � , " '� is not intentled or offeretl for sate�Section 7044,Business Other(Sec Compfele Fee Schetlule)_ ► anG Prolessions Code1. ' CONSTRUCTION LEN�ING AGENCY � � - " � - I here6y a�firm that ihere is a construdion lending agency For the . performance of the work for which Ihis permit is issued(Sec.3097, pEFMIi FEE � (Sub-Totaq � 105 $4 Civ.C.) PLAN CHECKING FEE � � � � � � �� � � � Lenders Name PEFMR ISSUING FEE � � � ZO SO - � �� � � � Lender5 Atldress � I cerlify that I have reatl this apptication and stale that the above TOTAL FEE . . .- . . 115.9(y - . . . . inFormation is correct.I Agree to comply wi[h all County ordinances . , and S�ate laws regulating ElcMrical wiring,and hereby auihonze . . . . . . . . . .. , . - _ representatives of this County t0 enter upon fhe abwe-mentioned ' - pCp 7t nSpeClion pufposeS. � ,-^n n r,� �� _��� -SEE REVERSE FOR EMPLANATORY LANGUAGE �7G1A/i'_ LI�,.I(J �I (#,«�.— � - ignaNre of I r o,te . � � ^ - 1/'. 'i� i , .. � . . , . . _. �. . � . �s . . .., , .. _ .. . �i.. ' .. t��_ . _ . � ._ . � ' . . •- - . . . . , ` �� �,��-�.,_. _ . _ :J... '_� - � `-._ ._ 7. � � � , _._.._._.. �.�.___... . .._._ _. _...'.. . . , ---...._ _._._ __.. . _.___ ____ ..._......, _ . ,�� ���,-'� aPa�toUalS oa7e�-- iNSPecroa 5� "� �_ . . , > - ---��-�-' ONlNER•BUILDER DECLARATION � � { . _ ._ SIGNATURE ' . . . . �...� E'� , , , _ � �- � ' - - �� � I hereby affirm that I am exempt irom the Contractor's License I _,___ ._-_-_--�-_�-. _._. 7EMP.POtYEA POLE -�.. �. :;.. ���: :..� � -r :.... .. . ..:. . . �y�.�for the tollowin9 reason fSection 703 7.5,&rsiness ana � UNDEftSLA6 VJORK�. ' �. ._ _ _ � � -_�_�___._...__ _..._. __ '� ; ' ��. � �' ! Protessiw�s Caiel:Any cify w counfy.wh)ch requires a pAvnit ! . ._.. ._______ .. . . . ' AOUGH COPJOUIT � � �-- -� � � � � ' � :,�, : to constvct,alter,imp�wc,demolish,w repeir any strucfure,pnor �.�- . , .... - . .. _ i. . . � fo i[s�lssuance,also mqvi�es fhe nppficarr,for sueh permit N�'Sqe � �� NJIRiNG , � � � , . , , �.. � a signetl stalcmmt thaf he is IiccnsM pursuant to thc provisions ' i �� . , �i ... ....._ ' �""� � "�"��""-��- �- FIXTURES������� ��-- �- - ' � . � I o/fhe Con7xtor's�Lkense Law(Chapter 9(eommencing with , I. . ,_;.� .. . -�_' -� - �' "'.... - � '., i ��,:.Seciion�7000)0/Divisicn 3-o/.tne&siness and Professlons �- -- '-- - �- �- ----- - POVlER�AUTHOR4E�--- � - �- � � ���-� - � Code) or�tha��e'is exempt themGom'ond the b.isrs lo��[�e - �----------- —- --�- -UTILITY CO.NOTIFlED -- , � ' ' ' � c�leged exempfion.�Any vioWtron o�Section 703 7.5 by ony � � �� �pplicant fa a permi(sub(ects Ihe applican(fo o'dK!pena;ty 1. -- --._..____.___.__.__ FlNAL----------jiyltCY011rYOT1Z� � '�--����-� . . . . ., alnotmorctnanliw�hundrMdoll:vsf850D): ' � .� � ' ' � ❑1,as owner of the property will tlo the vrork,and-�he . . . NOTES ,., , . i ._ _'_" ' . �� --- �-- -- - � --� - � -- - --- -- � ;. ; � . structure is not intentletl ar'olfered tar-sye.... . �, _(�, � - �-� � ., '�; -. , � �' � � � �� , � (Sec.T044,Q�iness ancl Professions Code: 7Te Con✓rx:�N s` � _. ..._ .. . ...._ '. ._ _ .l'' ' i � . � � � � , �'License Law does not a,opty fo an rnmer of property who buifds _ . �� ,. .,�, . , � . � - - � � '� , , ; - � - - �" -- - � � 'or rrnproves fhercat�arrd who tloes such work hi.msel/pwiaed __ .__ _____.__ . . _____ ._ .--, � , � (hat svch iMprovements are rrot intendetl a o1!aed ta��salc.!1, _..�. � .. i� .. ; , ; --- �-- -- ------ ---—.-� . � -. I ; � � .._ __ . �. ..., y hw:evci,fAe bullding or'rmprovemsnt is sdd within rne ycar of . ___ ._ ._. , .. . . � campletion,thc rnvna-buUder wal!have the bLrdan o/provin�th�t ,-.�. -:... . _' _ '_ .. ..__.._._._ ._ i- i , . '� ' ne'tlia not builtl orlmprove fwlhc purFose o1 sale) ' ' ... ��`� ; , � � . , ,. . , .. . � . . . i -:�.;�i � �, '� � � r� .- _.___ _." __ _. _ . , . i .. _ i I - .-. ' �. -._. ,._ '_..___ _ . � _. '.._. , , ' ._ . . . . . . � � � � � , ' � I am exempt under Sec. , . . .___.;. _. . . , , , . , . ,. . .. . ._. , �. � . � � c: . ... '� ' '�--- ---��----.- - � -- --._'-. . _ __ ... _. . ._..-� . �.� � . ..� � . _. : - , _ _ � .� . - .8 B.F.C.for lhis reason �� " � , ._____. . __�. _.. .- '� ' ' Date- � - . .. .. . . � � , .., � i � . . � .. .. . � � � i � �, � O'wner -- . , i � .. ,. . , . ' � ., .. . . � � - . . .-�- ------ -- -- � � � ,� , ., , , , . .� ` . �' __._.I .._ � i ' ._ : . . � , . � .., . ,...� � --- . . -i , . � �� � . ,. , . . . � . � _._. , , s ., ,. . , .. . . �_.. ..--. -.._---_. ___-''----- -.__.__.. . � � . �. . . . . . . .. .. _ -. ,� , .. . , . ._ i._ _. ._._., . . . _ ---,. ._; ..... _- __ _. . . .; ., ,. . . __._...- ' - .. -- --_'- �- - �,� , .. ,