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HomeMy WebLinkAbout0980A 1 NJORKERS'COMPENSATIDN DECLAR4TION � 76A663 �0,8, qppLICATION FOR ELECTRICAL PERMIT {� I I hereby affirm that I have a Certificate of consent to selt insure, C6B06G � or a eertitica!e af 4Yarkers'Compensatian Insurancc,or a eertified COUNTY OF LOS ANGELES BUILDING AND$AFETY LJ qopy thereof(Sec.3800.Lab.GI ' 1003782 STATE FUND Policy No. Company FO(1 AVPLICMIT TO FlLl IN � JOB 24275 BRECKENRIDGE LOT 39 ❑ .Certilied capy is hereby fumished. New Fesitlential 81dgs.8 Pools EACH N0. FEE ADDRESS � n Certitied copy is iiled with the county 6uilding inspection 1&2-Family,$q.Ft. �(159 $ — S LOCALRY DIAMOND BAR TR 42571 �r dq�artm L . MUIIi-}3rttily Sq.F!. � NEAREST �—��'� E S� D ELECTIC IN .' Residentia�Swimming Pools Caoss sr. � Date Applicant Fi�a NA� M.J. BROCK & SONS�INC. CERiIFICATE OF EXEh1PTION FROM WORKERS' Outlets:Rec—Light—Sw._ � `' � � MA�� � COMPENSATION INSURANCE � � � �� AD�RESS P.O. BaX 350 (Thie sectioo need not be compleled H the work Involved by lhe Firsl 20 permit Is for one hundred dollare(3100)a leos.) � Total No. Atlditional CITY � . Tel.No. _ I certity�hat in the perbrmance of ihe work for which t�is permit . PLAN LHECK � is issued,I sha!I not employ any person in any manner so as(o � APPu�� ��become su6ject to the Workers'Compensation I.av✓s. . L'ghting Fixtures , First 20 ADDRESS � - Total Na� Additional - _.w��e - Applicant CITY �. -� TeI.No. � .JTICE-TO APPLICANi: If, after making ihis Certificate af Fixetl Appliances Not Over 1 HP pERMiT Exemption,you should beceme subject to Ihe Workers'Compensation Range_ Heater_ D.W. _. APPl1CANT E & D E provisions of the Labor Gode,you must forthwith comply with such Oven_ Dryer_ W.M._ ADDRESS 319 MC ARTHUR T,iYA �bl prqvisions or this permit shall Cc deemed revoketl. .Top ._ FAU �W.H._ LICENSED CONTFiACTORS DECLARATION Hood_ Fan _ Olher_ CITY ' UPLA� Te1.�.g46— �I hore6y alfirm th�t I am licensed under provisions of Ch3pter 9 uGENSE OR . (commencinq with Sectlon 7000)of Division 3 of the Business and Disp.�_Room Air Cond. _ REG.NUMBER � C'�% PfofEssion5 Cotle,antl my IiCP�se i5 in}ull fofCB end effCct. DISTRILT NO. PROCESSED BV . Power Apparatus 8 Large Appli�nces �/� Size&Type HP,KW,KVA,or KVAR �U 1'ICe�p � License Num6er 422589 Lic.Class C'lO � -- Up to 1 InCL FINAL � � � -� E & D �LEC ��- . over i�0 10IncL �ATE � �-� VAUDATION � Contractor Date O ❑ Over 10 to SO lncl. I am exempt under Sec. _ Over 50 to 100 Inc. gy�� � �U 0.8P.C.(or Ihis reason Over 100 a -� �Services,-Swbd.,MCC 8 Panelboards • , , � � � � - - N Date: D-200 Amp.Under 600 V ^ � Signatum - 207-1D00 Amp.Untler 800 V � �� � - . ❑ �- �� �- � � -- Over 1000 Amp.or Over 600 V � -� Exemption for Fieg.Maint EIecL - ��- .. . . .. . '��" � SINGLE FAR1ILY � Tem Power Pole 8 A � � �O c1�.O R p. ppurtenances HOME OWNER-BUILDER DECLARATION Sign with One Branch Circui� �• • ° • �C 1 hemby afflrm that I am exemp[(rom ihe Contractor's License lzw Additional Si n�ranch Circuits � � � for ihe foliov+ing reason(Section 7031.5,Business and Professions � 9 � � � � ° � 2 J�� coa�t: • � i 3 2 5 8= � ❑ I,as owner of Ihe ra Mise.Conduits&Conduetars - - -� � p perty,will do ihe work and the structure Other See Complete Fee Schedule)_ � O e.2 4—8 7 is not intended or ollcred tor sale(Section 7044,Business ( ► and Professions Code). � � -� � � � - . � CONSTRUCTION LENDING AGENCY � - � . I hereby alfirm that there is a eonslruc�ion IerWirg agency for the performance of[he work for which Nis permit is issuetl(Sec.3097, pERM17 FEE - -(Sub-Tota7) 1 � � �� Civ.Q�. PLAN CHECKWG FEE . . . . I . _ . lentlePs Name , PERMIT ISSUWG FEE 10 Q . ., . , � _ . Lender's Address I certity tha[I have read this appl�cation and state that the above TOTAI FEE ' 13Z.$$ . . ', . . .. . . . info�mation is corred.I agree to comply with a�l Counry ortlinances anA State laws re9ulating Electrical wiring,and hereby authorize � � representa[iycs of this Counry to enter uoon the above-mentbned - � �- �- � " � - � r pert orinspection puryoses. ` I� �`��'�.. . .. . SEE pEVERSE F08 EXPLANATORY LANOUAGE __. . . . . . . . . Si ure of r Date � _,.. _._ .. . __. . .. _ �—, . E: . . . , � . �. .. ._ �. �`� . :a:. . � � , . _ • . , ' � � �_ ;:, . ; . �_, ,- ::: , c� �. ,.�..�_: . . . , .,,.. . ,_ . ..� . " ' __ ..�._.."'_..'__' ...��SIGNA7URE__. _._ ,i.. .... .. .__.. ..__ - .. , . , . .. ..-. . "' _ INSPEU NS ._ __. __ ..`' �.__�._. .��OWN . . � ' � ' ��� ' AaPaOva.�S � - DnTE ER-BUILDER DECL`ARATION � � ' . _.--' - .-.. -- , , r- � � �-, � �.�• �� -�- -- �- -� � - . ' � ' � �'- � ; I hereby alfirm ihat I am exempl from the Contractor's LicenSe ' -� � �.:.. TEMF.POtVER POLE ��� -�-i �` -� �� � " '�� � � j -. .L;,�H fer.the Iollov�ing,reason(SecGen 7031.5,Business�and . __ ___ __—__ _.__.. _.� . . .. � � UNOERSLAB NlORK�:- _ . - _ ._. . .'._. .. ._..__ . . .� �, �. � �.'� � P�olessions Caiel:Arry eiry or counfy which iequires a permif � ` . - .- ._..._ . ..... - �.� .':," ' �'to con,huct.alter,�improve,demolish.or re�ir anY swcture,Pria , ". �,' . ,. .ROUGHCONdUIT .. .. ._. ._ _.. __ _._ _ � . . .., ,.. � � 1 � '��- - �� �� - ��-�(o its issuahce;�also requi�es tM apofic'urt!or sucA permif to tile ;__ __..__ ._ . _.. . . . �P/IFiING,� � �g�� - � _ �_ i�� _ , � . � a srgned st�fement thnt he is lieensed pursuanl to fhe provisiwrs i _'. .. .. , . � o/the Crnhactor's Lkense Law(Cnapter 9(commrncing wilh • . . ___.. .. _..__ . ____. . � � � � . ,. � FIXTURES� - ., --, - --- ---� �- �� . ' �*"�':Section 7000J a�Oivisiar 3 0(fhe Busines;and ProJcssions . ..�.. � .� � '`'�� � i Code) or tha!�he��s�exe , . . ` ....'-"�"'"-... .POWER AUTHORIZE�� �...... . . ..... .... ..��-- �-��� i mp.�(hemlrom and the'�G�sis lor!hc -- UTWTY CO.NOTIFlED � - '�r�e9ed exemption. Any violatmn oi Secfron 7031.5 by�arry �-� ----�--- ---� �--�-� . � . . . ,, ,, �� apPlieant lo��a�pe�mit subjeets Ihe zpry'icant to a eiNl pena8y - �f1lPY O� � . . � . � � . . .� � -FINAI:-� ���� ��� ��- � . IZ 1'YOi7l � � ' o/nol morc t�an live hundmd do7a5(S5001:� ' '.._.__.____._..__.. ____. ��. . .. � ._. . _.N.^,TES.. _._ � ' � � ' -"-" -'�- '� ❑I,fls owner of the prCperty Yiill do Ihe V�ork,t�nd t��� � ' �i ���,' ��� � --� 6IflIC�Uf215 f10[Ifltefldf�Of Of�Cfe(�}Of SaIE. - ----- - � � - . i� ' '. �� , . � ' ` (Sec.7044,Busirtess artd'Proless;ons Cotle:�The Contractu,s , r ._ . _.___ ' _' •__ . . " -� -��� , ' � , .� "-� -- � Lleense Law apcs not a�ly to an a^mer ot properly who 6uilds _. ; � .- _�-._�_ �_._._ _.... _ ._� � � - � � -- � � � � or improves lhcrcon,rind viho tloes such Nrork himseff provlUetl � i . . , , th.i[such lmprovements me not�in(ended a ollered tor sale.Y/, . � �_ � �� . . „ _ . ,..-. ' - - -.-.---_ ._ __��. . _ _. . ... �. � . .- � ..__ �.� , ._.__ . . � havever,�Ihe 6uiltling or impio��ement is sold w�;hin one yca!ol ' .. . . . _,, �� � , ` '� com Iction,Nc am�er-buildc�w�7!havc 1he�bwden ol rov�rig that ....�i ,..._.._.._._..._�_.. .__'.,"..... __......_._., . i � , ' hc did nof budd a nnprave lor thc Purposc ol salc)p' . . �� ._,i � � . . . . . . .. • ,, i � � ,. . •. � �� . _. _- .r. '.�_ ._._'____.___-� ____.. _.. .; ; � - ,- „ -. ,., . :1 i- � F,s�- , . � . , __._._ .. ._.. _. .. �� ,. . ._ ._.._ . . . .. _.. . .. . . �_. , ... , . �. ...' ..., . . : . � ; � .. --.-.. �I am�exempt under Sec. ... �.� , , _ , . . . _ _. .. _.. __ ... .--- ... __.. .. .._ .. . _ . � - � --� - .. . ..--- - - - ���� �:.` ' . ' -� � . . . .. + . --.B&�P.C.--for this reason �� . � ,�. ' ' ._..._. _., __.._.._..._ . . . . . ... . . � _ __-. Date�—�----�---.__. ... � � - . ., ,-� . . � . _...__._. _ . . .. --: < . . . _ .. , � _ . , �_i .. � � �. � , . � Owner -. . � , . , ,.. . �, . . . : . -.,. . .. _. i . �. _ � ; _., _ ._. ___- �i . .. , . . . � � _ _----_- . -_..... _ _. . _.._.. . . ,.. . �.. . . . . _.._.__. . � -� - - -__ ;-- _---- ---- �------ ...-- - _ . _._ ; ;�- ��i i . _._- - - - - -. __. __ __ . , - _-._. _:-_:_... � _..__--- ---.___._. __._..__...___.._.___F_.------- - � , , - . .� :� ' . �.. `- :.,� . � _.__ " _. . _ . .J .I . . . . . '