Loading...
HomeMy WebLinkAbout0977A (5) I WORKERS'COMPENSATIONDECLARATION 76A663 �a�e� pppLICATION FOR ELECTRICAL PERMIT {� I hereby affirm ihat I have a certilicate ol wnsent to sell Insure, �68os� or a certiticate ot workers'Gompensatron Insurence,or a certi'ied COUNTY OF LOS ANGELES BUILDING ANO SAFETY �� copy thereof(Sec.3800.Lab.C.) Por,cy 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 �� t&2-Family,Sq.FI..� 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. ReSidEnlialSwimmirKJPoOIs O�YNEROR M.J. BROCK F� SONS INC. - FIRM NAME 7 CERTIFICATE OF EXEMPTION FROM WORKERS' �'� � '• .� ��' MAIL , , COMPENSATION INSURANCE� � Outlets:Rec_Light_�Sw.— '� pooaess � - First 20 itThia sectioa need not be comp7�tad H the work Invdvsd by the . CRY .. '.�RS�EFaH� BREA Tel.No.SZ9—HZ�O permit Is Iw one Aundred dollan(5�00)or�ass.) Total No. Additional PLAN CHECK I certity that in the pedormance o�Ihe wo�k�or whicb Ihis permit " APPLICAN7 is issued,I shall not emDtoy arry person In any manner so as to become subjed to the Workers'Compensation Laws. Llghtirx�Fixtures . First 20 ADDRESS � � � � Atlditionol /� � Totnl No. CI7Y � � Tel.No. -•�` '9 Applicant � � � Fized ApFliances Not Over 1 HP PERMIT . .JTICE TO APPLICANT: If, after making this Certiticate ot A���� E & D ELECTRIC INC. Exempl�on,you shoutd become subject eo the Workers'Compensatlon . Ran9e_Neater_D.W. _ , provisions of the La4or Code,you must lorfhwilh comply with such Oven_Oryer_WM._ ADDRESS 319 riC ARTHUR WAY �.1 pmvisions o•this permit shall bo deamed revoked. - . Top _FAU _W.H._ � � CITY UPLAND ��7eL�No. � �LJCENSE�CONTFiACTORS 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 � � cws:.C-10 (commencing with Section 7000)ol Division 3 0l the Business and Pfofessions Code,and my IiCCnse is in tull torce and eHect. ppy,�,+r ApparaWs 8 Large Appiiaflces - , D�57aICT No. PROCESSED BY S�ze 8 Type HP,KW,KVA,or KVAR LJ Q�d n Q Ucense Nutnber XX �L22589 Lic.Class �—�n � �� Up to 7 Incl. � FINAL 0 7_/(7 y� Ovcr 1 l0 101nc1. _ �ATE_ •�/� $�j VAUDATION � 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 y,� 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 f 000 Amp.or Orer soo v . . ... <0 9 7.7 Fl Exemplion for Reg.Maint Elect. ��� -� SINGLE FAMILY � � Temp.Power Pote 8 Appurtenances . . . ��"_• • • •� � '� ' HO�dE ONJNER-I3UILDER DECLARATION Sign with One Bmnch Circuit I • � � �j,9(j I hereby allirm that I am exemp[from the 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 thc slruCture Misd Conduits 8 Conductor5 � � ��i,'�[��S 7 is not inteMed or olfered tor sale(Section 7044,Business 01her(See Complete Fee Schedulel_ ►_ . . . . . antl Proles5ions Code). � CONSTqUCTION LENOING AG[NCY � -� - � - � I hereby nffirm iha[ihere is a construdion lerding a9ency tar the � perlormance of the work tar whiCh this permit is issued(Sec.3097, pERM1T FEE � ISub-Tolal) 1�5 [y � Civ.C.1. pLAN CNECKING FEE ' - � Lender's Name PERMIT ISSUING FEE � - �.O O - - - � Lender's nddress 115.94 1 certify that I have re�tl this application an�state that tne abwe � TOTAL FEE . � � � - information 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 enter upon Ihe above-menfioned . 6r inspection purposes. - SEE REVERSE FOH EXPLANATOHY LANQl1AGE - �� - - - - � � � �� Si aWr 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!?.POWERPOIE' �. ".�r : -�;.. :.� �-� . , ... � . ' � � � � � ' ' .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 � .