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HomeMy WebLinkAbout0975A (5) WORKERS'COMPENSATIONDECLAR4TION 76a663 �o,e, qppLICATION FOR ELECTRICAL PERMIT I hereby aflirm that I have a certilicate ot consen[to self insure, CE•eoeG � or a certit�cate ol Workers'Compensation Insurance,or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY copy thr,reoF(Sec.3800,Lab.C.1 �4�� Poiicy Na 10�3782 �mpa,y STATF. FTTND pOR APPLICANT TO flLl IN JOB ❑ .Cer6ficd covY is hereby furnished. . - EACH NO. FEE Aoo�iess � BRE KENRIDGE LOT 34 , � New Residential Bldgs.&P ols $� Certified copy is liled wilh the county buiiding insvection 1 E 2-Family,Sq.Ft �052 $. — S LOCALITY�DIl�O� BAR TR 42$71 ��part nt � � � MWti-family Sq.Ft. — ��E�T , � ^ •�� Residential Swimming Pools CROSs 57. o�te A,pl'�canl F b n'F7.F�'t'nT �7u�, owN�aoa M.J. BROCK & SONS INC. • - - FIRAA NpME 1 � CERTIFIC COM�NS T^IONI NSURO CWORKERS', putlets:Rec—L'ght_Sw._ � �ESS � P O. BOX 3SO First 20 c�7v . IIREA _ Te�.No. 529-5170 ,(This aeCtio�need nol be completetl'rf the work Imdved by the Tolal No. Addilional �pe�mH is 1or ona Iwndred dollars(57001 w�ess.) - . � I certify that in the performance of the vrork for which this permil .. _ . P�nN cnecK � is issued.I shall not employ arry Person in any manner so as to ����M become subject to the Warkers'Compensation Laws. - L'ghting Fixtures First 20 �ADDRESS - - - ' ' � - Totat No. �ditional CITY - � Tel.No. •.�`e Applicant Fixed ApPliances Not Oa�er 1 HP .�TICE TO APPLICANT:�11, after.making this Certilicate ol PEar,vr Exemption,you shouid become subject to the Workers'Compensation Range_Heater_D.W. _ AaP�ICANT provisbns of�he Labar Code,you must lorthwith comply wlth such Oven— Dryei_WM._ ADDRESS 319 1`1C ARTHUR WAY ��1 1 provisions or lhis DErmit shall be deemetl revokeC. . Top _FAU _W.H._ . � - CITY UPALND� � Tel.No:� 946-2131 LICENSED GONTRACTOflS DECLARATION � Hood_Fan _Other_ �� I hereby aftirm that I am licensed under provisions ol Chapter 9 Disp. -_�Room Air Cond. — uCENSE oa (commencing wilh Section 7000)of Division 3 01 ihe Business and PEG.NUMBER 422589 Class.C-10 . Prolessions Code,and my license is in full lorce and effect. ppwer Apparatus 8 Large Apptiances OiSTRILT NO. � PROCESSED 0V � Size 8 Type HP,KW,KVA,or KVAR (O ��� � License Number fi995R9 Lic.C�ass � lJp to 1 IncL � � FINAL � - � y Ovcr 1�o t0lncl. DATE � � �Contractm. E & D . •. .� . Trii{B'�"� � —� -�-� .VAl1DAT10N Q Over 10�0 50 Incl. FINAL ~' ❑ I am exempt under Sec. Over 50 to 100 Inc. gy . .. , _ _..._ W 8.8P.C.for t�is reason Over 100 y . , . Services,Swbd.,MCC S Panelboards , - � ' �- - -- �- � Z -�Oata 0-200 Amp.Under 600 V � Signature 201-1000 Amp.Under 600 V ' � ' �-- - �-�" � � " � � �� Over 1000 Amp.or Over 600 V ❑ Exemption for Reg.Maint EIecL � - " :`_D 9 Z 5 A ���' SINGLE FAMILV � � Temp.Power Pole 8 Appurlenances � ' � .:✓ HO�dE OV/NER-BUILDER DECLARATION Sign with Onc Branch Circuit � • � '3 2.'S� I here6y affirm that I am exempt from the Contractors License Law e o � 3 2,5^G= (or the tollowing rezson(Section 7031.5,Business and Professions � ���iona�Sign&anch Circuits �� . .. G � �a�� ou2U-87 Misc.Conduiis d Conductors � �� � � - � ❑ I,as owner o�the property,will tlo the work and the structure Is not intended or olferetl for sale�Section 704a,Business Othcr(Sce Compiete Fee Schedule)_ � and Protessions Code). � CONSTRUCTION LENDING AGCNCY . � � � � � � � - I hereby a�firm that there is a construclion Iending pgency for Ihe � performance o1 the work lor whfch this permil Is issued(Sec.3097, pERMR FEE (�+6-Total) 1 08 � � Civ.CJ. PLAN GHECKING FEE� - � - - - � - � �� � � � � - - � � - � Lender's Nome ' � . PERMR ISSUING FEE � . . . . . . . ._ . _ .. Lender's Atltlress � I certily ihat I have read[his�appllcation and state that the above TOTAL FEE . 132.$$ � - � � � informatian is correct I agree to comply wilh all Coun[y ordinances and State laws regula[ing Electrical wiring, and hereby authorize . _ .. .. . . ... . . . .. _ re resentati es ol this Counry to eMer upon ihe abwe-menlionetl ro vty r inspection purposes. . f � „n� ��� SEE REVERSE FOR E%PIANATORV LANOUA6E � - . - � �� --� Sigr��r of P Date � ,_, , .. . ... ... . � � .. , . . . . .._ , , ,_. . . . , . , � ,. .. . . _ . . _ . _ .. i.� .,, ,_ ..�. .._�_.. �.,.. . :�.,... . ,. �___ _. _.._ _. . ._.....__. __� ..____ ._._.._ .. _. . ..__.._. ._____ _._ _..._ ' ir�s�ecTor�'s ' � ; -- --".-'--OWNER-BUILDER DECLARATIO� : _ ;- • c,:-��., .• ��,� APPROVALS. ,_- _DATE -. . r SIGNATUFi° .- . _ ._. .__.� . .._ . .. � ' . .. j ., . I..���.i ,., 7EMP.POINER POLE�� � - � - _ �' ' � ' I hereby alfrm that I�am exempt(rom[he Contra.^,tor's Lcense _ _. ... ... ,. , ,� r_� �-, . ,. � ' ' ��' � - '` `-'� ' � ��'� - � Law 1or the follovAn9 reason(Secfion�037.5, BusLaess�and ,__.'_. ..___.____._.-_._ -- ' � . , � t UN�ERSLAB YlORK�. � i. . .. .. __ _. _ _.._.. _ '� ;- �: � ':' ; Pro/essions CodeJ:Arry city Or eounty whrch repuires a permit- . i_.____ __. .. ._.. . .�. , ... . �. . to consLucG aRcr,ur�prwc.dcrnolish,or rtparr arry Stazlur0.priw 1 � � � ROUGH CO"JDUIT - � -- - � � � --�i � � ��•-�-�-�01ts lssuy�ce,hlso Iequires the npplicai�t!a such pemrit to file .." _ . ... . . , 7.______. .___. ____.__ .... . .___...____._ . _ 6"✓IRiNG , ���`���/2;..�-�-j �'� •. � � .� --.. ' a signed 51a!emc�rt that he u d'censM pimsuant to the prwisions � �� �� . . . , �� ��- _�,, - �- -- ol the Crnhxlor's'Lkense Law(Cha,fer 9(commenang wifh .___ ... . —�-FIXTURES.,. . . ..._ , � � .,,,.;,. ...�-- . � .__ _. ...._.__._,_.. _ ___ . . .��• „, ' , .,,Secfion�7000)ol Divi,+ai 3 of fne Busirmss and Pro/ession: i �--�------------- POWEF AUTNORIZED���� � "�, - - ' � -���-�� � � � -�� � � f Cotlo) Or that he is exempf There(rom and fhc his$�lor.the � . , � �� aF.egetl esempfron. Any vlWatim of Section 703f.5 by any ._.._-_.__.__.___..__..___._-UTILITYCO.�NOTIFlE�_._. '. ' • .. . . � �apphc.int lor a pemNf sub�'eets Ne n�6eant�to a eiL!!penalty t ..---_"- .FINAL__._ _.. ; � - . --�-�,�--'--� �� '. . . �� ' ' � � . � .o!not morc than fivc hundred dollnrs(S500jr' ' ,. .' _.______. — ... .- , - I'}itcr oll Tront � � NOTES __ � � �� � ��'�� - � ❑6 as owner of the property wll tlo thc work,and Qic __ _ _ t... . __ ._ _._._'__'_.__ .__.. _._.. . ' �, I '� . . � ._._..sVucture is no[in:ended or.oftered for.sale._....__ _ ..->. 4 ... ... ....:......: �„ :: - , . . �. � ., � .� ' � ", - �' '. �� ' (Sec.7044.Qusir�ess�and Professians Caie:�7he�Cantrxw... ;_.___.___ . _ .,. ' . -. _� . . . L' 1 d t I t I � h �b !d ' " �cense auv oes no epp y o an owner o propc y w o ur s � � • . . �..�. . �.� .�. � :�'�: ' � , i -_ � '�.: ' : ---' � � � �'a irnproves lhereon,and who does such wak hirrr;e!(pa�ided �._ "' . .'_ _. _. ._ ' _ ... . . . , , , , . , that such improvemen[s n�c no!in'ended a o8cred loi;alc 71, ,.-- -.- �� `....��,�_--.-. �.�-�. _ _ . . � . I � , �� ._ _ �- ��� . � ___ � � ' ' howeve�,the bui�ding or lir'ryxovement is-'sold withrn one yrnr ol __. ,_' ; . _ . , _ �,._.,___ �_,_ ._ .,._ _ _ . . ... �� ' �eompletion,the owrrcr-buildcrWill fuve thc buMcn of provint�Ehaf �. � _..:.._ __.__...._ ..�.__._._.:_..�__ _.._... ._. .., . . � � ..� � . ...vc fa�1he pu.�pose of saleJ . ..,,. , � hc tlitl no:�bu.;d 0I Irnpm,, . . . . .. �i, f .�4�� � .� � �i �,, . � , , . ' '_ � •' ' �'.�. . ' _...._ _ ._. _ .._ ... __ ,�� . . I , ��� �, � � . . . ,. I. -' � . . .. _ _ .. _ __._. . • - ' ._. ._ . --._ . . . . . .,_. ._ .. _ ..._. .., ' ' � I am exempt under Sec. ._ , . ,.. ,.,, ' � . � � , . . �� , . , • ' --. _ -- .. . _ , ,. , , _: ,. _ _:. . , -- _.. , ,_ i: � , B&P.C.for this reason — ___ 1 _ _._.. -- -, � , . . ,.- ,, i _...._.__ .._ .__ . _.. __.. . .. � . _.._ ..___ . � , � __._Date- - --- � .. . � ',, �., ' �'� Owner .. . . .. � . ... . ; . . . . � � ._... .. . .'�:... � . � . . ``� _ � . , ., .,.. . „ . . � ., . , . , � .... � - � . . ._ -_. - - - - ---- . _ .. -. . ., . , . . � - , . ., i, ... _._ � , . .. . i- .I , . _. .. � � . .. ., .. . . . . �_. i — - - i i - - -. ...__ __ . _— ._. _ . �