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HomeMy WebLinkAbout0977A I WORKERS'COMPENSATIONDECLARATION 76AB63 �a�e� pppLICATION FOR ELECTRICAL PERMIT {� I hereby affirm ihat I have a certilicate ol wnsent to sell Insure, �68os� or a cerrrcate ot workers'Gompensation Insurance,or a certi`ied COUNTY OF LOS ANGELES BUILDING ANO SAFETY �� copy thereof(Sec.3800.Lab.C.) Porcy No. 1003782 �,,,R„y STATE F[JND FOR APPLIC�NT TO FILL IN ADDRESS 24245 BRECKENRTDGE LO ❑ Certitied cooY is hereby furnished. New Res'dential Bldgs.8 Pools EACH NO. FEE �� !&2-Family,Sq.FI. � 4� S _ � �oCAuiY DIAMOND BAR TR 42571 Certilled copy is (iled with ihe County building inspection tleparlme�.' ' Multi-(dmily Sq.F4 NEAREST CROSS 5T. Date '� Applicant E & D ELECTRIC INC. RESidE0liBlSwilnmifKJPo015 OL'lNEROR M.J. BROCK b SONS INC. - FIRM NAME 7 CERTIFlCATE OF EXEMPTION FROM WORKERS' �'� � '• .� ��' MAIL , , COMPENSATION INSURANCE� � Oupets:Rec_Light_�Sw.— '� pooaess � - First 20 tThia sectioa need not be comp7�ted H the wo�k InvoWsd by the . CRY .- '.�RS�EFaH� BREA Tel.No.SZ9—HZ7O �• Totat No. Additional permit Is Iw one Aundred dollan(5�00)or�assJ . PLAN CHECK I certity that in!he perform�nce M Ihe work�or whicb Ihis permit " APPLICAN7 is issued,I shall not emDtoy arry person In any manner so as to become subjed to the Workers'Comperwtion Laws. Llghtirx�Fixtures . First 20 ADDRESS � � � � Additionol � Total No. CI7Y � � Tel.No. -•��'e Applicant � � � Fized ApFli�nces Not Over 7 HP PERMIT . ..7TICE ro APPLICANT: If, after making m�5 ce�c�r;cac� or A���� E & D ELECTRIC INC. Exempl�on,you shoutd become subject eo the Workers'Compensatlon . Ran9e_Neater_D.W. _ , provisians ot the La4or Code,you must lorthwith comply with such Oven_Dryer_WM._ ADDRESS 319 TSC ARTH� ti'AY �il pmvisions o•this permit shall bo deamed revoked. - . Top _FAU _W.H._ � � CITY UPLAND ��7ei.�No. � �LJCENSE�CONTRACTORS DECLARATION Hood— Fan _ Other_ — �1 hereby atflrm that I am licensed under provisions of Chap'.er B pisp. _Room Air Cond. _ REG�NtNe ER 422589 � � cwso.C-10 (commencing with Section 7000)ol Division 3 0l Ike Business a:id Professions Code,and my license is in tull torce and eHect. pp�r ApparaWs 8 Large Mptiaoces - , Di57aiCi No. PROCESSED eY Size 8 Type HP,KW,KUA,or KVAR - � Q 1 d n Q Ucense Nutnber XX 4225$9 Lic.Class r—�n � �� Up to 7 Incl. � FINAL 0 7_/(7 y� Ovcr 1 l0 101nc1. _ �ATE_ •�/� $�j VAUDATION Q Conlractor E & D ELEC Date� (T���t Ovcr 10 to 50 Incl. �r � ' U ❑ FlNAL I am exempt untler Sec. Over 50 to 100 Inc 8Y /y {,tl 0.8P.C.for this reason Over 100 � N Services,Swbd.,MCC&Parelboards �� � ► ' � � � � � � Z Date: 0-200 Amp.U,�c1er 600 V Sign�ture � 201-1000 Amp.Under 600 V ' � � � - �� - .❑ . . - . Over 7000 Amp.or Orer soo v . . ... �_0 9 7.7 A Exemplion for Reg.Maint Elect. ��� -� SINGLE FAMILY � � Temp.Power Pote&Appurtenances . . . ��"_• • • •� � '� ' HO�dE ONJNER-CiUILDER DECLARATION Sign with One Bmnch Circuit I • � � �j,9(j I hereby allirm that I am exempt from Ihe Contracfor's License Law Additional S�gn Branch Circuits -�-�- - � � - tor the following reason(Section 7031.5,Business and Rofessions e � 11594s coaz�: ❑ 1,as owncr oF the propeity,will do[he work and the slruCture Misd Conduits 8 Conductor5 � � �S,'�[1�S 7 is not inteMed or olfered tor sale(Section 7044,Business Olher(See Complete Fee Schedulel_ ►_ . . . . . antl Proles5ions Code�. � CONSTqUCTION LENOING AG[NCY � -� - � - � I hereby nffirm iha[ihere is a construction lerding a9ency tar the � perlormance of the work 1ar which this permit is issued(Sec.3097, pERM1T FEE �� ISub-Total) 1�5 [y � Civ.C.1. � � pLAN CkECK1NG FEE � ' - � Lender's Name PERMIT ISSUING FEE � - �.O O - - - � Lender's nddress 115.94 1 certify Mat I have re�tl this application and state that tne abwe � TOTAL FEE . � � � - informatlon is correct.I a9ree to comply with atl County ordinances . and SWte laws rcgulating Eleclricai wiring,and hemby authorize _ . . � . .. � representaty�as ot this Counry to enier upon the abovrmenfioned , 6r inspection purposes. - SEE REVERSE FOH EXPLANATOHV LANQl1AGE - �� - - - - � � � �� Si atur of Permit:� � Date - _ i ._ _ . . _ . . �. _... . _ , . . , . .. ._ . ._ ..a ._ . . . . . ' . _ . . . _ , . � ; ; , . _ �, .. . �- _ .. . ; . � . ,_�.�. . ,. . . . - 1'. r.:�..5 .,�� 1 ;-,�:•r - �.. , . . , .�. _ _, . . ., r _.. - -•� � . ... . . � , . . ,_...__.�. - '---- �. _.. _ ..._.___. ...._.__� .. ._-' .._. ..... . � - . ._ ._,_._ . _.___._.... _.___.._ i ,, . .. . irisae�toa s � _� �'� . i .�.'-: '�_��ONINER-BUILDER DECLARATION �. -� ; .�� . :��-. .;APPROUALS �, DATE--- �SIGNATUfi[ . , ....._ - ._ ..-. , ' - .�� � - i- - - - - -� � � - � � I hereby affirm ihat I am exempi from lhe Contractor's License ' �\��. !' I TE,L!?.POWER POIE' �. ".�r : -�;.. :.� �' ,� , �� i . ' � � � � ' ' .W�+for thn lailownc��eason(Sectim 7037.6,Busness"a�d .___ .___ - . i UNDERSLAB WORK � � ____ __ ._ . _.__-_�-__._ ___ _ _. . .. � . ; . . Anfess'ons CotleJ:Any ciry or camry which reqvires a permit ,. . . ---— ---- -- � . .. . . � ,to ronstvcE..lte�,nrpiwq Ucmolrsh,a rep�rr a^Y.truturc,piior � . •. . ..l� �ROUGHCON�UIT� . . --.---.____. __... . : � , .-� � . -. . ' _� _ '� -�• _ /' � ' ��- `fo!1s lssuance�a15o requircs�fhe applicaot fw siKh permir�fo L'lc '_ _--__ . .. _ . . .... ��I� .4YIFINCt,.:,-`, � i� ; ' . � - ,,.. ., j a sign�tl statemcrR Ne!he i�liccn,�d pinsuan(fo fhc plwisims . _____ _._.. . _ _. � � , � ! of!he Contractor's L+cense Law(Chapte��3 feommeneing with i �.-.,�,` . ... � ; .,, ..FlXTURES :.. . ..._ .______. �___.._ . .., : �.�.i�..SeCfion�70001 of Ofv�iai 3 c!fhe Qusirmss and�Pro!essrbns � � � � "� �� � Codc1 or tha(hc�i5 cxem t tlmrelran and the G�sis Id.7he ....._.... .__....... .__..._.__ PO'�N[R AUTt10f11ZED - _.� . "_- �-.,. ._ ..-� ..I . . , P . . � - '�� anc�ed exemplion. Any via�a6on ol Sec;lar 7031.5�Cy r�rry ;�---� ----�- �-----------1IfILITV CA.NOTIFIED�-- , � � ��� ,cnnt�/w a evnit su6.cts ihe n fcant lo�a ciW! mt . . . � - ,.., . - � �PP� P 1^ PP' P<'"Y _ -_ .. __..-. _. .FlNAL.. _____ -J�37tC'Y 0)t��YOltf . .. .--..� . . . ��. � �. ! ; o(not morc thsn five hunCmtl do1/s�s($500J:.. . ' � � � ' � �- ` ❑I.as avmer of thc property will tlo Ihc work,and t�r ' ' NOTes �'� � I •, : - -� - - -� - � , .structure is not intended or offeretl br s�le.... � •• .._ __._ . ___ ... _.____ ._._ . � ., . . .. . I � � , ,,.�.� �' � . �. . � � � - - �� __.,.._� . _ __, � , . . ., ' ' . 'i i � � , r . . u '{Sec 704¢,Qusiness vrtl Rale:sions Codc:'The-Con✓aci .. _� i . . - Lieense Law does not apply to sn owner ot pmperty wno-puilds .. . .. .,�� i . , � � . : ��� �� � --- - � � � �br i, roves lhercon,arM who does such'work himseN prwided i ._ .__ . . _._ . _ . _ . _ .. � , ._ ,. , � ��,_, , . , , lhal suCh unpiove.menfs are nef mfenCed or o0c�cd!or sale.d, . . _.. __..__._ ._. . .'. ._. ._.J . I , I .. . _.. _. . _ .. r.�' � hovmve},'fhc bulfd�iv oi I . - - � , g mprovamont is soW wRhin ane year o! , _. . . . .��.__. -�_ -_.. . . ._ ____. -_. . . , .. .,�.tanplclion,thc avncr6uBdcr wi.�l haw!hc burdcn al pfov'rng�ha. �_.__.,._._.... ._._.__.._.�.....____...._..:_ :.:�._.�. -�� � �'- he dd not 6b�ild or 1mpro�e!or fhc purpose o/Saie) ��� � :i �/ I , � ' I �. '. . . .. . , .__ � . . � , ::�� .... . . .. I _._. .`__ � ._-. - � � � ' � �I .,�, .. _. . . I am p un . . � . . _ .. . . � exem t der Sec _ ,.. _ .. . , . . ...__.. .. ._----' -- . _. �•� ���" �� ; -.-...B&.P,C.for.this reason ' � �-._.. . . � . . ; ... . �' � -'--- - -.__----� ..--�- - --- - . ._ _ . _. , i'.- �-� - . '._--- _ _- - � - -- - �' � ; __.._----._. _ � . ._:� �� �.. � � ., ,. _ -�Date - - . j '� I ' . t Ovrner � -- . , . .i.... ._._. ._... __._. . . ;:� _,. .., . . ,-�� , . � . i � �.. , . . . . . � , .. � � � . .._ �, ._;_.._...__, __.._ _I_._--- - - --� � . . � � ..... . _ . .. .. �.............--� - ------__...__. _-___._�.._� ' . .., . . . , .., . .�.. .. , .. i, ,� . . ., .� .,, . . . . _ . . . . � i� ___--._---_ ._ _.. . ___. . �i i _ . _ _ ' '��� ' -_-... ___ . -.._-.- . . ., . , .. . .. .. .. .. . ... . �� .. ., . : .. . �. - . '.1 � .