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HomeMy WebLinkAbout0982A i WORKERS'COMPENSATIONDECLAFATION 76a663 10�g� APPLICATION FOR ELECTRICAL PERMIT �' � I I�ereby aNirm Ihat I have a certificate of consent to self insure, CE-eOeG or a certlticate of Nlorkers'Compensation�nsurance,or a certiticd COUNTY OF LOS ANGELES 600 BUILDING AND SAFETY cvpy thereol(Sec.3800.Lab.CJ . Aolicy No.•1003782 �Company STATR FTTN11 Fqi APPLICANT TO FIIL�IN � - ' � � JOB ❑ Cenificd copy is hcreby furnished. EACH No. pEE AooRess 24263 BRECKENRIAGE LOT 41 . . . .. - New Resitlential Bldqs.&Pools � �� Certified copy is filed wilh the county building inspection 1&2-Family,Sq.Ft.?��� $ — $ LOCALITY � �d�epart�e�n - Multi�family Sq.FL — NEARESi � Res'w'cnfial Swimming Pools - CROSS ST. o�ce�L`n—��Pu�a�t F �. T1 RT,FfTRT(` I � F�i'R^'MNAME pi.J. BROCK & SONS�IIv'C. � CERTIFICCOMPENSATnION NSL1R0 C5'UOFiKERS' putlets Fec—Li9ht—Sw.� . . . �, pD�RESS P.�• B�X 35� (This aection need not ba compleled R the work Involved by iho First 20 Tolal No. Additional CI7Y Tel.No. ,permit le for one hundred dollars($f00)or less.) — I cer[ify that in the performance of the work lor which this permit , � PU+N CHECK , is issuetl,1 shal�not employ any person in any manner so as to APPLICaNT become subject to the Workers'Compensation Laws�� L'ghting Fixtures First 20 ADORESS '� - - � ' Additional ���� Applicant � " Total No. G7Y � - Tel.No. .i ICE �TO APPLICANT: If, aNer makin9 this Certificate o1 Fixed Appliances Not Over 1 HP pEqMiT Exemption,youshould6ecomesubjectPothe Workers'Compensation R�ngO_NCdtfl_OW. _ APPLICANT E & D ELECTRIC INC, Drovisions of the Labor Cotle,you mus[forthwith comply with such Oven_Dryer_ 1N.M._ ADDRESS 319 MC ARTHUR WYA �f�l , provisions or this permil shall be deemed revoked. � .Top _FAU _ W.H._ � LICENSED CON7RACTORS DECLARATION Hood_Fan _ Other_ ' CITY � UPLAND Te1.N0946-2131 I hereby affirm thot I am licensed under provisions of Chapter 9 ��cENse oa (Commencing with Section 7000)of Division 3 of the Business and O�sp. _Room Air Cond. _ REG.NUMBER -C�ass _ Professions Code,and my license is in full force antl eflecC Power Apparatus 8 Laige Appliances oisratcr No. aROCESSED BY ' Size 8 Type HP,KW,KVA,or KVAR I D �pl�p f�e � License Number 422589 �c.C�ass C-10 Up to 1 Inc�. FlNAI E & D ELEC ��I�—�-- Over 1 to iD Incl. DATE ��� VALI�A710N � Contr2ctor Date � Over 10 to 50 IncL � � � FINA F— ❑ I am exempt untler Sec. ,. Over 50 to I�O lnc, gy �U B.SP.C.for this reason Over 100 � Services,Swbd.,MCC 8 Panelboards � ► � -- - � ^ �� � Date: 0-200 Amp.Untler 600 V , � Signature ��201-1000 Amp.Under 600 V � . � - - � � ��� Over 1000 Amp.or Over 600 V . �\ ❑ Exemption for Rec�.MainL Elee[. � � . . _ . . .. . -��"� �' - SINGLE FAMILY � Temp.Power Pole 8 Appurten�nces '� r 0 9 E.2 A + HOME OWNER•BUILDER DECLARATION Sign with One Branch Gircuit � �� �- I hereby altirm ihat I am exempt Irom the ContractoPs License Law �:� ° • • ° •2 � for the following reason(Section 7031.5,Business and Professions-� Additlonal Sign Bra�ch Circuits �_ , code): 1 • 1 1 5.9 4 � Misa Conduits 8 Conductors � � � r = I,as owner of the properry,will do the work and the slructure Other ISee Complete Fee Scheduie)_ ° � � a 9 4 c� is not intended or offcred lor sale(Section 7044,Business ► and Protessions Code). � � � ��G(j��,7 CONSTRLICTION LENDING AGENCY � � � � � � 1 hereby aifiim that Ihere is e construction leriding agency for the � �. performance of the work for which ihis permit is issuetl(Sec.3097, pERM1T fEE � (Su0-Totap '1�5 [�[� " - - Civ.C.). �. PLAN CHECKING FEE - . ' . . . '� . . Lender's Name � . PERMIT ISSUING FEE _ . ZO SO . . .. . . _ Lender's Adtlress I certify that I have read this application and state that the above . TOTAL FEE 115.94 . . .. .. , ._ . _ _ information is correct.I agree to comply with all County ordinances antl S[ate laws regulating Elecirical wiring,and herehy authorize representatives oF this County to enter upon the above•mentionetl � � � ��� - � � -� � � � � � � - � propert t 'qspection urposes. �. � � ���^�.. . _ .SEE REVERSE FOR EXPLANATORY LANGUAGE. . . . ._ _ . . ... .. Si u of Date .-_ . ... ...,._ , , . . ..... .. .... �-, ..,.. ,,. . ,.. ,_ . ,. , :r.,-�� _ , �.i ,; • .. . � �.... ,.., . � , C!, . - . � . � ., ... - . . . , .... .. . .. . . _. . .. .. ... . . �� , � i. , , . � .. .. � . , . i ' � . � ., �.i(. . ."' .., . .�, .. . „ �. _ �„ .�I . . :J . � .... . _ . , .� , .._.._. . _.._. . __....__...._.--'.._.._. ...._-'�' " ' . ....._-_._. ,,....._._ ._._.. ,__.. 1 �i� ;�,- �. I:, : '� £aPPRovaLs -��--oarE- �r� aecroR�s . __��.. . ._... . . ... . � ---- ���----��vNER-6UILDER DECLARA710tJ �.���.�.r .. _._. ._ . ..__ ��SIGNATLIRE - � � � -- -�- �-- -- � � - � � '�� I i hereby a(�irm th2t 1 am exempt fmm thr Cont•actor's Licere ; �- . , : TEMP.POLVER POLE����� ,.', - --� ,•, �-�; . - � , .____., �_.� .�_.-� . .__._.: � _,....,. .-. ... �� . E ,,. .�•r�for thc tollowin9.reason(Section 7037.5,f3usibess antl -�'-� � � - -��-� - �'� � P�otessions Cotle):Arry tity or county which�equires a pe�inif ; UN�ERSLAB VlORK ���"' - . ..___:___. �� '��_--� ...-: _.. .���-�::qOUGH,COC1�UlT� ,. ._._. ....�_. �.. .._. . -�. � . . . . � ;' :i 1 :10 consWct,alter,unprrne,demolisli,m repalr�a.ry�struefure,Priw ' �� ' '� � "�� � ' ' i fo'its'lssuaoce;afso reGuires the epp�icant ler such permit to)i!e __._ -._._ ....___ .. , - 4'11RI�:G , �g � .. _, ,. ,._ � � , � ` a signed s!alemem iha!ho is licensed pursuanf to tl�c provi:✓ons ' --�-- --------- ---�-- - � -�- ��- - ' : j ol the Conhacta's Llcerlse Law(Chapfer 9(commencing with '� .._. F(XTURES .__�__._ . ..._"_.: -_� �� . - �-• � . �� , �� ��Seclion 7000)of ONlsion 3 0/fne Bus'rress�and Pro;essions -�'-'"- `�-""�"�-"-"�""'" 'POVJER'AUTHORREO".�� - � �-� � - �� �- -- - � �- �� ; Cotic) or�(h5t Ac is exemptthaefro.n and thd�h�sis f�Ihc � �----��-'�-'�--'� -"��--�' UiILITY-CO.MOTIf1ED-��--� 1 ' � '. �� �alleS�exemplion.Any viofation o�Sectton 7037.5�by arry � � � , , � � appAeant for'S pcmiit subjccts thc app6cant to a'clvil pen.Vty . � --- -----�-�-��- �FINAL-------�� ; I 1'Y011t �. . � � � 01 nof morc inan livc hundred dolla,5(5500): � � . �...__._._n�o7E5..______ �71rCY O1 . � ' ❑I,as awner of the pmperty wiil do the work,and!ho ..-_ _ —_""_ ' __'___ � � , . ' . . , . . i . -�---struciure is noi iolendetl or otferetl 1or sala� �- ""� �" ^_• ..,,_I. . , _ ', ., ' • � .. : ;.- . . - :�'.. ,_ _ __ ,__ ;. . -.. I . , , _ ; � "�(Sea 70J4,Business and Professions Codc:�7t�e Con6�c,,,,,s . ._. _ _._.. . _... _._.. _ , . . , � , . ' Ucense Law ifoes'not apply ro mfaaner of property�who�buiids _. .__..__'__ ......__ . __..._.__. ..__.1 ' -.... _� . .. ...... ; - 'oi irn,raves therear,and who�tlxs such w,rk himseff proi�itled , , fhai such Impvvemenls arc not intended or o!lcred fa sa!¢ll, . .,. . .. ..�..:, • �, ; � . �.� .- ---���- �-���-��--- �-�- -� - -.... _ . � . - � . .-. . -_ � � � however,fhe 6uifdm9 a rmP�ement Is sald wr:hin one ycar ol 1 :...-. .:�.: . : '� � ' ��completion,the rnvne�Wdclw 1he pulpos�o�sa1�provinc�that .,�-.--'--'_ ._..,-:_...'----` . ._ _ . � . .. � �, � . ,.�he.did nat build or i . �, , _ . I . i� i • . � ; I • . . , . . �..i , � � , „ , , '- �� ' . , ..,, -.. • _ - _:. '. ..-. _._ . .._ . _ . . . , . ., . _,. ii�--�i . ' •_:. .:� t_ . _'_'_"'. .... : _ _ _ ._ .', -. -� � - � � � � - - �-�.I am exempt'under Sea �� '� . ,.�-� �:- , . . ; ,. . ._.____. _ .__ ..- - - - . . ..__. � ._` `` . .�1. . .. . ��- - - , ... . ..-- -. �,' ' � � -� � , � --�-B&P.C.�for this reason � ' � ' .i I . _. . _ _ '. ' � -- ' :"� , . , . . . . . . . � � . -.I_ , , � , I .._ ._ . _ . ;._. ......__.. ._. _ _ . . . . . . . . . � . � . _ . _. .-- --_...__. ' . _. , . � . . .. Date -- -- � ; Ovmer __ � , , � ' - _ _ _- � r � .. .___ _ �.__1__ .._. _. _. . , � . . -.,. --. .. � . � "'.� . � . .- ' ' , . �..__�._... .__'_.-�._.. _._.... _ _._.______.._.______ . _ _.. � ;' .. . . i - � .. __ ." __ . .. _._ � ' . .. .._. ..._ � _ .r:: -': '�';:.'. � . � .__.___ '_'._ ..�-___ _ .__._...___"__ , : i - ' � i '-;' i ., � f_._. .. . . . . _ . _..._. ._..._ . � .� - ., ' "__. ..__._ -____.. . __. . . .� •'. ) . . . .. ... . ...... . �. . , . . . . .� .i, ` P �'