Loading...
HomeMy WebLinkAbout0969A i WORKERS'COMPENSATION DECLARATION 76A663 70/et � , �E-eos� APPLICATION FOR ELECTRICAL PERMIT , I hereby aftirm that t have a certilicafe of consent lo self insure, or a cer6ticate or Workers'Gompensaoon Insurance,or a certifed COUNTY OF LOS ANGELES BUILDING AND SAFETY copy ther o S OO.Lab.G.) 50� � � • �1bb��1$��2 STATE FUND FOq APPLICANT N FlLL IN JOB . Policy No. � Company aooaess 2426G BRECKENRIDGE LOT 28 ❑ Certi[�ed ccpy is hereby fumished . New Residential Bldgs.8 Pools EACH NO. FEE . [� 1&2•Famil Fi. 3291 $ 04 _ $ IOCALITY DI 0 Cer[ified copy is liled with the county builtling inspection Y��� ��. p3rlm'nL � . - MU��f-(amily Sq.Ff. NEAREST. , Residential Swimming Pools CROss St __ JL2te � Applicant F & D I.F.TR7C TNC .. F°aMruMe M.J.�BROCK &S ON � - CERTIFICATE OF EXBMPTION FFOM WORNERS' _ . bt�� � • � - COMPENSATION INSURANCE . Outle[s:Rec,Li9M_Sw.— � ���, P.O.� BOX $SO �;(Th(s section need not be complsted H tAe work Involvetl 6y the Flrst 2D .`.mi�is r«one hundred doilers(5100)or IeesJ Tot�l No. Additional c�Tv BREA Tei.No. 529-8170 •I certity that in the perlormance of the wo�k for vrhich ihis Oermit . � Ap�puCA�CK .is issuea,1 shail not employ any person In arcy manner so as to become subject fo thc Workers'.Compensation Laws.. L'ghting FixWres First 20 ' ADDRESS � �� Additionnl Appiicant Tolal No. CITY Tel.No. :-R� Fixed Rppliances Not Over 1 HP � .. .,�ICE TO APPLICAN7: II, after making this Certificae nf PERMir Exemption,you should become subject to the Workers'Cqmpensat�on. Ran9e_Heater_D.W. ,_ APP��CANT E & D ELECTRIC INC. provisions of the Labor Code,you mus[foRhwith comply with such Oven_Dryer_W.M._ AD�FESS�� � provisions or this permit shall be deemed revoked. � . ToD -- FAU _ W.H._ _. ciTv ' UPALtr'D rei.No, 946-2131 UCENSEO CONTRACTOAS OECLARATION Hootl—Fan _Other_ �I hereby affVm ihat I am licensed under provisions of Chap7er 9 -�Disp. —Foom Air Contl. — UCENSE oR . CWss (eommencing viith SCction 7000)of�rvision 3 of tho Business and REG.NUMBER _ Professions Gode,and my license is in full lorce and ef(ect Power k.par�lUS S L3fQC ApPIi�tlC25 OISTRICr NO. PROCESSED BV �'• Size 8 Type HP,KW.K�A,or KUAR ' Q � � License Number�22589 Lia Class C_l� ' � " �� ' Up fo'-t Incl. � FINAL �- �- � - E & D ELBC �—�C�—�� Over 1 to t0lncl, DATE�Z��.. � VALOATION � CONractor � Dale - - Over 10 to 501nc1. � O ❑ FINAL U I am exempt untler Sec. Over 50 to 100 Inc. BY yJ B.BP.C.for this reasan Over 100 (L �� Services,Swbd.,MCC 8 PanelboarAs � � � , � � �� � � �� . � N �ate: 0-200 Amp.Undcr 60�V - ^' _ Signalure 201-1000 Amp.Under 600 V � - - � - - � --.� o�c�i000 nmP.or ae�soo v -0 9 b 9 A ExemDtian for Re9.Maint.Elect. �• � • • �� � SINGLE FAb11LY � � �� ' Temp.Power Pole&Appurtenance5 �� � •1 4 2.1 4 HOME ONJNER-BUILDER DECLARATION Si9n with One Braneh Circuit � D���2��`i� I here6y altirm thot I am exempt fmm the Contractor's Lkense Law qdditional Sign Brarich Circuits for the following reason(Seetion 7037:5,9asiness and Professirns� �. � - - Code): � I,as owncr of the �Misa Conduits&Conductors � � p�operty,will do the work and Ihe structure � � �s not intended or offered for sale(Section 7044,Business ��her(See Completo Fee Schedu�e)^_ ► and Professions Code�. � CONSTRUCTIONLEN�INGAGENGY � � �' � � � I hereby affirm that[hcre is a ronstruction lentling agexy�or Me . perlormance of ine vrork for which ihis permit is issuetl(Sec.3097, pERM1T fEE - � � ISub-Totary 'j31 64 . �� � � � Civ.C.1. .PLAN CHECKING FEE - � � � � � � � � - Lender's Name � � . PERMIT ISSVING FEE _ . I.O SO � . . Lender's Address . . i certify that I have reaC Ihis appilcation and stafe that the nbove 70TAL FEE 142.],4 _, , _ .. . . . , Information is correcl.I ngrec to comply with ell Go�nry ordinances � and State laws reflulatin9 Elecfrical wiring,and hereby authorize . _ . , .. representatives of this Counry to en[er u0on the a6ove-mentioned � or Inspection purposes, SEE REVERSE FOft E%FLANATORV LANGUAGE �`°� . , ' ' ��{ �_ _ �9naN�e Itle� Date . ( I . ,i� _.i,� t .. �_ . . [ . . .. . . � .. .. .. .... . � �. , . . . . , , , � ' .. _...__..._.. - ...__ _....�.�......... ....�..........�... .�.._....�. ..�........��_....._. ' ._'..'__.��_�_�._�_..._.�..�.-�._. .. . ..� .. . . . _ (� .i. , �:�.�::' . , _trJsr�ecroR�s '��:'�.�� '�.. _ .._--- ' -. .- .--.. .-OWNER•BUILDERDECLARATION ' .. . '. . .�.'�� 1�' � ':'. �. ' ��'.AhPROVAIS ' -_ DATE-' � ..SIGNATLIRE . ., _ . . . ��.: .___ __.. __ � : ��. . . . . _. ..... � " �� � � ` � Lav�lo�Ihe�1 ��wlname��e.m�t�Iromt��Conl��rac�r'sLicense f- -� �� 7EMP,�POWER POLE� ' ( . ,'i. �:, ��.� i r olio g reas n ec ion . , si ess antl . ._._., . �._._ . .__, , .. . . . . � UNDERSLAB WORK � . .._� ._.._.'. __._ _J. _ __...._ ...; �� . � . � ,. .�Ro/essiorr�Codel:Any city or county wblc�requires a permit � 1 '� ��'- . ..- . .-- .. '.. � . � -'. ... .. �}�,alfer,�impro✓e,tlemolish,or.repair ony struCNre,P�ior ROUGH�ONOUIT. ' �.. ..� "... . . ..�._- . . . . :� . . i �._ro co '� � '_��:�� "'� , - to-if�suance;alsorequireslhcapplicant/orsuchpermitl�"JI� � _._._.._._ . .._'.. . _ i . ; , �WIRING,�� �� - -� .�1�-�"-��� _ _ _, , . , • a s tl sq!ement Ih�!ho is licensed pwsuant fo the piwrsions . ...--�-� ,. . ..._ -FIX?URES . ,.. ' -----.. - .. --- -- ... . ... ' .,., � '.Se�onC Ot00)o LlCensc Law(GAap!er 9 lcanmencing with _ � . � f O�vlsion 3 0/the CxrslraSs and Prolcssicns - �.�'�- ' ...._ ._ . .._. _... _�.._"" I Cotlel a'th�f hc'is ex�m . , . `."- "�'"�-"`.-'—�.._-. -POVJEA AUTHORIZE��-•� .� '� �� � -- , s - pt thcrelrorn end Ihe bas's tc•�'te -- --` UTIUTY CO.NOTIFlE� - ' ' � ! , � �' pplioint tpr a pertnrt sutry'eets�hc�plieant �031.5 by ony _ _ ._�_..._.__' � . .._'_ .,:,, __..NIO ES.___.. . E1i1CY Ot1 1'Y017i � ,. . ,. � �� .. .sirlctu❑re����nI tletl�e Drfer�ed lofW 5 d�)�to A Civl!PmaRy ' � � '.___ . , �..� � � . he work.aM�he ' ..._ ._ . I . .._ _. .. , , - fSec:7044,Business anrl Pro/esvons Coae:•Tne�Cmtrac�w's � �- �� �- �� ' � . - �- '� Lleensc Law Cocs irot apply fo ran wmcr ot property�v.tio builds 1 ....., .', .�. . � � � .- ' .". .'� . .. ' � : � Or imprv✓ec fhCieon,and Who d0es�suCh work himsCl/pipvldCd � �. � _.. . �.... .._:.._ _ ..._. __ _...: ! . ._ , , � , � � � , fh3t Such Lnarovemmis arc nOf intentled or ol(eretl 1or SalC.f!, � .�---..-. ....------- ----- ---- .. . .- . � r - - �� ' however,}he 6uilC;ng or inqvovement'L^sold wi,hin one yeer o! , .. _ ..._. . __ , . ,� � � eanpletion,Ihe oomer•buildcr wdf h�(he burden of ploving fhat �� �� �- � � � -�-" �� � i � �hc�id not build or hnp�ovc ror the � _ ._.._.... ._._.. _..�....�, . . _ . . . P�mosc o!salc.1 . _.. -.', ..r� . � ', � � � ... ,�;, . , ..._��. �_�._.�'- .,-'�-----� .._ : i , , ,. '� . r..�- •. .���� ; � � i.'-:; �.�:� :. <.. , .. , r r- . . ___ .....:__ ._.._ . , . ---_____ ---- , . ._. _ _ .. . . . � ,_ ., . , .. , ... . . . ' ; .� . ,_ . �.� ��.�-�_ ,.� �. ..-_ . --- '� . . � .. I __ r�. ..__._ _� .�f arrm exemPt under Sec. ._ �:� .� �; . . . , , . , . . .._�___. .. . .. __. _.__ . . -,� . _.�.__ :__-i-- --.. . _ --- � , ;.� � �.;.._. ��� ..i� . � . : . ' �-� �.. . : ' , , - -.B&P.C.-for lhis re2son - � � �' ' � .C. � �_..--�- --_.._ _... _, j . , ,.,_' ,-.,.: ; , � . ."".I.... __..._. _ .___:. .___. _'_ " _ . . r .. ._..;._.._. . _ _.._._ _ .., .. .. � .. . . � ' - :.� . � � ..,_ � .,.. , --Date__._. __. _ ... _ _ _ _ _. I j 7 Owner , , _ ; _ _ __ ' � r-. ... . _--.. ... _ .___� ._.. _ ..__. . .__._..._..----i .• � ' . , t _ ...._...__., ... ._ .�.. � _ �. ..___..._� , : � ., , i �. _. . . . ._._ -- -- -_.--_.. _.. _ ._. , ___ _. � - __ . . .. .'� �� � � ,, �. . : _. . ..... .. ._..-----. _. . � _... . . . .. _.- . .,' �i' : � _