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Home My WebLink About0974A (5) WORKERS'COMPENSATIONDECLARATION 76Ab63 �o�B� qppLiCATION FOR ELECTRICAL PERMIT � I hereby zfflrm that I have a certilicate of consent to sel(Insure, CE-8o6G� or a certiticate of Workere'Compensation Insurance,or a certitied COUNTY OF LOS ANGELES BUILDING AND SAFETY copy thereot(Sec.3800.La6.CJ � (�� Policy No. 1043�82 CompaM � STATR Fjjy� Fp1�PGLICANT TO FLLl M � JOB noor�ss 24z94 BRECKENRIDGE LOT 33 ❑ Certif�ietl copy is here6y furnished. New Residential Bldgs.8 Poo�636 $�H NO. � FEE ND BAR TR 42571 � Certilietl copy I5 liled v+ith the couNy buildirg inspection 1 8 2�Family,Sn.FL — LOCALITY epart nt � Multi-tamily Sq.FL NEARESI ReSidential Swimming Pools CROSS 5T oate '� l4�•4�- Applicant R k n Fr Fr�rurc_IN� a'vr�R o� . & SONS�INC, . . , . FIRM NAME � CERTIFICATE OF EXEMPTION FROM WORKERS' ' � �+�Ai� COMPENSATION MSURANCE OuHets:Rec_Light�Sw.— . . � aooRE55 P•�• BOX $SO �;,This aecl'w�need nol ba eomplelad if tM1e work hwolvetl b the First 20 y Total No. pqditionat - CITY BREA Tel.No. pesmit is for one hundred tlollars($100j or Ieas.J P�nN GneCK � 1 certify that in the pertarma�e ol the vrork for which ihis Dermit � � ppp��qy7 - -� is issued.I shail not employ any person in any manner so as to � become subiect to lhe Workers'Compensation Laws. Lightirg Fixtures First 20 ADDRESS �� , - Atlditional ^� � � � � � � Total No. CITY � Tel.Na. -�./ 'e Applicant � Fxetl Appliances Not Over 1 HP . _JTICE TO APPLICANT: If, after making this Certificate of PERMR Ezemption,you shoultl become subject to the Workers'Compensation R30gC_HC'3[Zf_�.W. � APPL�CANT E �D E�TRIC'IN provisions ot the Labor Code,you must farthwith eomply with such Oven_Dryer_W.M._ AODRESS 3I9 MC ARTEI� T�AY �`I • provisions or ihis permiLshall be deemed revoked � Top _.FAU _W.H.� . . . LICENSED CON'fRACTORS DECLARA710N Hootl—Fan _ Other_ . aTv UPLAND Te�.No.94�_ � I herehy aHirm fhat I am Ilcensed untler provis�ons of Chap[er 9 . Disp. —Room Air CAr1d. _� UCENSE OR ZZ $9 Ciass.CL-0 (CommenCing with$eCiiDn 7000)OF�iVlsiOn 3 Of�he&1Sif1C5S�fld FEG.NUMBER Prolessions Code.and my license is in fult torce 2nd Bfle[L Ppy,�+�ApPaf2tU5 8 L3fgB ApplianCOS DISTRICT NO. PROCESSED BY 4225$9 ' Size 8 Type HP,KW.KVA,or KVAR �� '"5.'.C, License Number Lia Class C-lO - Up to 1 Incl. . � FlMAL � `-� � � ' - � V r�77� Over 1 to 10 Incl. OATE . 7/Xi1 VALI�ATION � ContractorE & D EI,EC Date ` �� - - � � �� - �- � O Over 10 to SO lncl. FINAL �-' �� ❑• I am exem0�under Sec. _ Over 50 to 100 Ina _ BY . � . � � B.&P.C.�or lhis reason Wer.100 � Services,Sw6d.;MGC&Panelboards - � � � � ^ � Date: 0-200 Amp.Under 600 V Slgnature ��201-1000 Amp.Under 600 V - �� o�e�1000 Amp.or o�e�soo v -�0 9 7,4 A Exemption tor Reg.Maint.Eleet. ��- SINGLE FAMILY� � 7emp.Power Pole fi Appurtenances �� 2 , r ' HOME Ob^/NER-BUILDER OECLARATION Sign with One Branch Circuit � � � 1 �g�" � I hereby affirm that I am ezempt from ihe Contractor's License Lavr Adtlitional Sign Branch Circuits ., . e e � � 9 br the following reason(Section 7031.5,Business and Professions u �� coa�;�: . 0 6 2 4�_8 7 ❑ I,as owner of the Oroperty,will tlo the work and the structure Misa Conduits 6 Conductors - � � - � � . � - is not intended or oflcred for sale(Section 7044,Business Other(See Complete Fee Schetlule)_ ► aM Professions Code). CONSTRUCTION LENDMG AGENCY �� - -- � � � I hereby affirm lhat there is a co�s[ruction Ierding agency for the performance ol the vrork for which this permit is issued(Sec.3097, pERMiT FEE - � (Sub•Tocaq 105 �44 . � .� Civ.C.1. PLAN CHECKING FEE . . . . . . . _ ._ . . Lender's Name � PERMIT ISSUING FEE _ 1 O . .. � . Lender's Address 115.94 I certify that I have read this apv��catbn and state that the abrnie TO7Al FEE information is correct.I a9ree to comply with all County ortlinanCes � and SWte laws regulating Elecirical wiring,and hereby author¢e �� representmives of this Coun[y to enter upon the a6ove-mentioned � � � � � . �- � - pro ert for'r�s?�ection purposes. gEE HEVEHSE FOR EXPLpNATORY LANGUA6E. ��`��`r,.a.v� �'{g'�� Sign re o Pe i e Date � - _ � , , — __ - c_ _ � '� +� _ . . i ; .. . , _. .. : _; . . , • .i_. . ,, . ^� -•, ::;:� _� . .. ., ' - - _' , . _. ..._._. ._�.. _.._ .. __ -- ,. � � ' � '�'�'.."OVJNER-BLIILDER DECLARAI`ION..:, � r ^ .: . A E MSPEClOR�S �.. . ._... .. .�. � " ,'�, � PPROVALS -. ----DAT '�, ,'SIGhJATURE - � �- ' �� ' j��.�� • � � � -�- ---� --- :�� --. ,�� _ � � � � � I hereby affirm that I am exempt from the Con!ractors Licen3e . � I'� �,' ' TEh1P.PObVGF POLE �.'�'. .� �' ��. • � �.... __ _. _. .. �� . . ;-� . '' ' t � : �. Law far Ihe followin�rcason(Sectlon 703J.5.(7usincs5�and ; UN�ERSLAB WORK '�� ,- ._._. . . -:.._ _� .__. � . � '".' Professlaas CodeJ:Any ciry a�county which rcquims a pc�mit � `._ . . . .. ._ Y ._... �-,� �.. . � ROUGN CONDUIT "-".. . .__. . .. ..,W eoru^f�uci,alter,ioyuove,CemolisA,w req�Ir an strvctrne,Prioi ' ' `� �' � • �'to ifs rssuance,a75o re�vires fhe applican!/or 5uch pem�if In Be �....._._._._ _._,_.__._.._.. ._ .. � ; . �,�.-; _WIR�Na:,'� -`_ " , , -' ._. .�_ . . . ._. .. � . , a Signed sf3!emen(that Ae is Iicensed Aursuant fo the provisiMs FIXTIJRES ' ' o/fhc Conhxtor'S Lkense Law�(Chapler 9(Commen[ing with ____. . ._. �.__ .._ � ,.�...., .,, - � .. . � �� - ��''.Secfion 7000)ol Drvision 3 ol�tno&niness antl Pro'essiocs � � i Codc) cr fhif hc is exem zf�- --� ..".��..-��--�"-�-� �POVJEFi AU"fHORIZED�.�:- ....._.. .j--- � - - . � � Ft th,emfiom aod the'hasis for'thc I , I ' ' aReged exemption. Any violation ot Section 7031.5 6y o�ry ._._._..__._.—.....__._._._._-�TILITY CO.NOTIFlED � �� I � . . . . � -� riaplicant(ur o pennit suq�ects(he eppliconf to a civil penalty '.._.__-_-_______.__.______ FINAL. . ___.-.-j�YlIPT O12/�1'UYII - ... . . .. .• � � o/rrof mac fhan fivc Nmdmd dolia5($5001: . j � . � � ..___ _._. .. ❑I,as owner of ihe praperty will do the work,antlL� j... ._.__ .._ _._� ____.NOTES_.. � � ' i � .., .,,,• ; --. structure is rrot intended or o(fired lor sale.-� - �' - �� ..,,.. . . i. . _, . .. .._ . ...._....' ' .''_.,� ....... ......_:..� . .�_ _ ��' . � � lSee.7044.Businc;s antl Profc.^,sions Codc:'7he Contxtt„s . ,, . _ - , ` Llcense Lar�tloes not appfy to an�o•roner ol prcperty who�bui�ds . i.. ,a .� ..., . . � .� . ., . � . . _ . . . . .. � , . __._._ _..____ _ . ___ . .__'_. _ _.. . ; � . .,., . . . w i� roves theieon,avd who Coes such�Y�ork himsc!! � _ _ _ , ', Prwided ,, , _, �. , , , , Lhat such!nprovemens are not intendc[i a�olMred lor sale.It, .--=..:_-' � _.- --�---�- ' -�-- -- .. �. . .'. . ' hou�mver,Ne 6u1lCrng of�in�provement Is soly within onc year o1 _ .. ' i � _ -_ ". . . . . . .._'_""...._.___....._..__.__'_'_•'„'.__.__..... . �. � �eompletion,!he owner�6uifdcr Hnil have ihe burden o!prrndn�[hat � ,, �- .,� . � ' ��he tl;d not bui'tl a improve lor ihe purpose ol sale.l i .. t l � r . � i , ,. � , � , , . , , . - � r � _,� _ — _ .. ;. , ,., � - � . ._ ._�. _ .._. . . - - -' .��1 am exempt under Sec. , ..: , � .__ _-� -- - - . . , ..�_._ ___ i . ... . . _. . . . . t.. , , � �--- -�B 8�P.C.for this-reason� -- � ._....__ . . _ . . . .. � � . . .. . . . .. -_ . ' + ----Date.. .__--.____. . . ,., �-�' . . . � n .,.,. . . � . ' � . , � ._.. . �� - �. . , - - . � Owner _ . i . ..,. � . � ., . � . . , _ _- _ . - -..--. i . - ,__. , .. . ..__ . -._..._. _ .. -. . , �. �� . � . � . . �.. . �'� . ._. . _ _ . . . . .___-�- ----------_. . . _.___ � . .., ,... � , � . ,...-`-... _.--.-._------ ------- --�---- ------- . ,�. . . ..,. . ,.,�, , .�� ' , . . . �. . .. . . . . '� -; � -- � 1 . . ' . ' ' ' .�.�-�. �.