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HomeMy WebLinkAbout0971A (5) i WORKERS'COMPENSAT�ON�ECLARATION 7fiA663 toie� � � � CE-BO6G APPLICATfON FOR ELECTRICAL PERMIT I hereby affirm that I have a certificate of consent to self insure, or a certificate ot workers'Compensation Insuronce,or n certified COUNTY OF LOS ANCiE�ES 400 BUILDING AND SAFETY copy themof(Sec.3800.Lab.C.) 1003782 STATE F[7ND FOR APPIICANT TO FllL IN �� 24278 BRECKENRIDGE LOT 30 Policy No. Company � Cer[iliea copy is hereby furnished.. . . New pesiden[ial Bldgs.8 Pools �H NO. FEE ADDRE55 . � Certilied copy is fi�ed with ihe county buiW�ng inspection 1&2-Family,Sq.Ft. -}qq�— $� — g LOCALITY DIt�A�OND $AR TR 42571 pa�rt�y�, . .- Mutti-family Sq.FI. — NE°HEST .. . �E & D ELECTRIC TNC Resitlential Swimming Pools caoss st. Oato � ��� Applicant F��Nq� pi:J. BROCK &S ONS, INC. ��� CERTIFICATE OF EXEMPTION FqOM WORKEFS' Outlets:Rec—L'ght_Sw.— ' �\ � Mni� - COMPENSATIOPJ WSURANCE - �� ' �� ADORESS . ,(This section naed not be complebd H the work involvetl by the First 20 permit la fw one huntlretl tldlers(5100)or Isas.) Tota�No. Atlditional arv BREA Tei.No.529-8170 I certify that in ihe performance of the work lor which this permit nPP�iCAUT K is issued.1 shall not employ any petson in any manner so as to . become su6ject to the Worker5'Compensation Laws. Lighting FixNres First 20 � ADDRESS � -��� � � � . � � � . Total No. Additional CITV �- Tel.No. ��i"�•e App�icant Fixed Appliances Not Over 1 HP fICE. TO�APPLICANT: If, after making this Gertificate ef PERh„r �E �& D ELECTRIC INC. � Exemption,you should 6ecomc subject to�he Workers'Compensation Range_ Hcater_D.W. _ aPauCANi p�ovisions of the Lahar Code,you must forthwith comply with such 6ven_Dryer_ W.M._ ADORESS 319 MC ARTfiUR WAY ��]. piovisions or this permit shalt be deemetl revoked. � Top —FAU � W.H._. _ . � LIGENSED CONTRACTORS DECLARATION Hood—Fan _othc�_ c�rv -� UPLAND Te�.No.946-2131 I hereby.affirm tBat I am licensed undet provisions o�.Ghapter 9 LICENSE oR (commencin�wilh Section 7000)of Division 3 ot the Business and Disp. ,Room Air Contl. _ REG.NUMeea 422589 ��azsC—I.O Prolessions Cod0.and my liccnse is in�uil force and effect. � ppWer Apparatus$Large Appliances DISTRICi No. PROCESSE�Bv Sizc S Type HP,KW,KVA,or KVAFi ��Q rn � License Number 422589 Lia Class C-1� � � Up to 1 IneL � �� FINAL � - 7 Over 7 to 701nc1. �ATE �l`�� � conc�acror E & D ELEC oa1e C -�-� VAUDATION O Over 10 to 50 Incl. FINAL f" ❑ I am exempl under Se�. OVer 50 to 100 Inc. gy /1 V 6.8P.C.for this reason Ovcr 100 t �. � Services,Swbd.,MCC&Panelboards � � ► � �� � . �f 0 9 7.1 A. N -� Date:� D-200 Amp.Under 600 V � � � ^ Signature �201-�7000 Amp.UnCer 600 V �� - -� �• � �� � Over 7000 Amp.ar Over soo v � � ' � 3 2 5 8 � Exemption far Reg.Maint Elect. - �- -� � - � � � -� � • e � J 2,5 fi= U �_/'� � � � SINGLE FAMILY Temp.Power Pole&Appurtenances . . ��G 4„$7 HOME OWNER-Bl11LDER DECLAFATION Sifln with One Branch Circuit � � I�.vreby affirm Ihat I am exempt from the Contrector's License Law Additianal Sign Branch Circuits � for the lollowing reason(Section 7031.5,Business and Prolessions� - - � - � � - � � Cotle): - ❑ L as owner of ihe rt wilt do the work pnd the struCture MiSc.Contluit5&Conductors � � � - - � �- � � � ���� Y' Other(See Complete Fee Schedulel__ is not intended or oitered for salc(SeCtion 7044.Business ► and Pmfessions Code). GONSTRUCTION LENDING AGENCY � � � -� � I herehy affirm that there is a conshuction lending agerx.y for the � � _ periormance oi the work ior which Ihis permit is issued(Sec.3097, pERMIT FEE (�b-Tolal) - � � -- - Civ.C.). � . . PLAN CHECKWG FEE � . . . .. . ._. . _ . - Lender's Name � PERMIT ISSUING FEE . , . . ].O SO . . , . . Lentler's Address ' I certify that I have�ead this application and SWte ihat the above TOTAL FEE 132.5$ � . .. _ . . . information is correct 1 agree to comply with all County ordinances � and State laws regvlating Electrical wiring,and hereby authorize representatives of this County to enter upon fhe above-mentioned -� -�� - � � � � � � - � prc7per .ispectian purposes. SEE REVERSE FOR E%PLANATOHY LANCaUAGE / t ^�� _ Signj of � Date l ;'`.. .., ,� .,. ..:_ . . .._, e . '.... .. , � :.. . _ . , 1. . . . . . . ' ' I ` �- . . .. . ,_. ., . . .. . , . .. . .. . , ., .. .. . . ' . ' , � . `� . _. . , i i .._!it;.� !n, c.�_. ..�. . :.� � _ �.... . .... . . ' . r �� ' - . . . . � . .-."' _.' _.�..�_... .._. ..._�... ._..�-�_ .........__ _...._.. —_'_ �� ...i.., .. � , � v..�. .. . .irAr�ec.iO�rs_ ,.�.. '..' - - -����OWNER-BUILDER DECLA�,�..;. _ __ �__�_-_ . .. . ...'. ___._ � � APPROVALS `---DATE. . . �SIGNATURE �..-�. . RATION � .� �,.. _ . . .____ . �.. :�.' . �,I�� �" . � ! ��-�-- . I hereby aftirm tnat I�am exempt froin the Contr�clor's Lieense '!] ::TEMP.POV�ERPOLE- � i � � �---��--- -�--- -- - � �� _ � � � ,Lavi for Ihe followin9 reason(Sectrbn 7Q31.5,8wincss vid � � UNDERSLAB bVORK � � . ..'�-... _ _L .___.__._:_... _ ._ ___ ". . .^.,.' ; Ro/essions CaleJ:Any eftY a county y�hich reCuires a pnmi( .-.'. `.�. ...... .. - �. - •���m crom;Wcf,a/tcr,"ii rovc,dcmolish,or r �i an'structurc, ior ( . . . . , . . f1011GH CON�UIT . .. _. . __..___.. , . . � . . N� cP'� Y� W� ..._._. .___•'�_._ _'__. . . ' f . -.:to fts issu�nce.also req�ines Ihc apPGcanf la such pe�nit[a�i7r. : INIRING ' �� i �, _ ; . '; a signed sqtemenf thal he is flcensetl pmsuant ro the provisions � � � �� o!Lhe Conrmctw's�Lieense Law fChapler 9(eomnxncing with , _ .. _. .. __._ . . .. . . __ .. .. _� .� . , -.-, , FIXTl1RES --� . �---, ��- � - - - '. • '�.��Section 7000)ot Division 3 of the Business and Pro'es:iwu � �----- - ---"���"�"- �" POWER AU7FIORIZEO��"" � � 1 � � � �� �- � Code) or that�hc�is exempf fhcrefrom antl the�G�sis lor-.!i�e � . � � •�'� alleged�exemption.'Arry vidation o� Section 7037.5 by any ---- �---�-��'---�-- �-�- UTILtTY CO.�NOiIFIED�- ' � -j � . ., , �� applicant Por a pertnrt subjccts Lhc applicanf to a civil penahy 1__._'____..-__..—_...._ _ .FINAl-_.__-._- .j'17IC)'0)2 1'YOYtl . , � . . . 0�rrot more than five hundred BolLvs(5500):� . .. � - ' � � �� � �. ❑1,as owner of the properly will do lhe work,nnd fhc � i __.._ _=__'.. . .... ND£S_ .__ .. ___ ; � � i ..�. . � � - -�structure is not inizntled or offered for s21e. - --- . �__r.. ,._... ._. .� . . '.' ,�. �..'.� . : �. ' .. ' .. ___ , ,. � (Sec.7044,�E7usineuandProless�ons Cade:�Thc Contro� _.._ ..__. �. . � � �,. .;, ,._. ., � ., . ;, . . . � UCenSe LAw Cces not appl ro aa o�m,cr ot prq�c�ry''wlio huilds ' '� ' ' ' ��-- � -' ' - -�-�� � �� � o�impioves thereon,nnd v ho tloes such�wak himsel!p.-witled ,. . . . .� , . , , fhat sueh improvemmts am not�intenrled a oflerod!a ssfe.!1, i __... _____.__. .. � - . , � . .. . � . � _._'__'____. '_ ' ' ' . . � � _ . , � -- �- -- howevc�,�the 6viltl�n�or imp!ovement is soid witNn onc yca�07 � � - � � � � ' � � � �complefion,Ne a��ner-bupder will have the�burdcn of provrng tfrat __....J_ ..'_'__.......'_ _'_ .�_.:_.....� __.....: , , .., . . , - . ��� � . � � � . he did nof 6udd or iinprove/w!he purpose o1 sale.) � ., ., . ,_ . , � , � . i i . . . . ' -' � .r.. i , _ , i . � .,. , . . : ..,. _. __ .' "__.._._._ .. �, . � _. ,. '.. ��`- � ' � ' • ' ; ._, •_ �, t . �.�� . � � . . - „ .. . , � , : . . ,.. ., c:�� � �_-- - _ ._ _�..._ .� - -�� �, .._ - . � -`. IamexemptunderSec:,._. ,. - .. . . ; -- . _ ... ._. �:.-�_ .� . � ..� '. ' .__.. .. ... _ . . _ . .... �^..� _ _ _ ... _- � . . . CC I .___"-. - .. _. . �-' ' .. � ' ., ' �� `, ---B&�P.C.-for this reason � � � . . � � . . . __. ...-�_..._ _ � .. ., . , . - . . , __�-.Dale--- -- -.._ ..__.- --.... _. .. . . , . ,. . ,. ,.� . .. ; - _------ -_.. , .. . -i .. � ; . ,.. ., . --- _ � ' . Ovmer " � , , � �. �� . -� . � -- � ._ . _. � . . �:�. � � � . . �... . _ . .:. � . �__ _..__.._. . � .. ' . . . . - . ...i ,. ..._ _._ __. _.._. . � , . � '_.� . . ... .. _ _. _- ._ __... ------.: � - .., _.i_._ � '- - -_ . ._- � ---_ _ . ..E ._ � .. � _i t�. � . ,. � .. .. .. _. . �� ' !�.- ' ,� . . � .. . ._._._____.__.._... _.--. _ . .. �� : �.__ ---- i ... _ ,. � . \ � . . . � � .. , � . . , �