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HomeMy WebLinkAbout0976A { wuRKERS'CORIPENSATION DECIARATION �enesa ioiai r� � � CE-806G APPLICATION FOR ELECTRICAL PERMIT c � I hereby affirm tfmt I have a cer[ificate ot consent to selt insure, � or a ceriificate of workeis'Compensation Insurance,or a certilied COUNTY O�LOS ANQE��y� BUILDING AND SAFETY u coPy tnereqt�t��y�a�o.tab.c.l STATE FUND u Policy No.� Company � F�R�PP�-�NT TQ FK��N - �� �108 - Q Certifietl coOY is here6y furnished. � EACH NO. . FEE pD�RE55 24299 BRECYENRIDG New Fesitlentia�H:dgs.S Poo�s LOCALITV DIAMOND BAR TR 42571 � � Certifietl copy Is filed wilh the caunty buildirg inspection 1&2-Famiry,Sq.F[ 3291- § _ � NE/REST �rt t.��7'] � � ' Mul�i-lamily SQ.Ft. CRO55 ST. - � ��te'����Applicant E & D ELECTRIC INC. Residential Swimmin9 Pools FNn�AME M.J. BROCK &S ONS�INC. � CERTIFICATE OF EXEMPTION FROM NK7RKER5' Outlets:Rec�L�9M�Sw.— � MA�� � � COMPENSATION INSURANCE � - � '� ADDAESS P.O. BOX 350 � � (This section nesd not be compleietl N the work invoived by Ihe First 20 purmit Is M�ooe hurM.M do�lan(57001 a less,) Total No. Additional crrv . . BREA rei.rio.529-8170 PLAN CHECH I cerliry that in ihe perlormance of the v✓ork tar which this permit � � - arpuCqNi is issuetl,I shall not employ any person in any manner 50 as to become su6ject to the L'✓orkers'Compensa[ion Laws. � Lighting Fixtures First 20 AODRESS - Additianal � ��. Applicant � � Total No. CITY � Tel.No. � .IGE TO APPLICAN7: If, ofter making.this Certi�icate af Fixetl Appliances Not O�r 1 HP p�qM�T ' �ExemOtion,you should become sublect to the Workers'Compensatian Fange—Heater,,._ O.W. ` . a��°1'�T F, & provision5 0l the LBbor Codc.you must forihwith compry wich such Oven_Dryer_ W.M., � AODRESS 314 PfC ARTHiIR WAY �{�1�� provisions m Ihis permit shall he tleemed rewked. Top _FAU _W.H._ Ct1v UPA ND 7e�.tdo. LICENSE�CONTRACTORS DECI-ARATION Fbod_Fan _Other_ � 1 hereby a!tirm tha�1 am licensetl unCer prwisions of Chapter 9 Drs _Room Air Cond. _ uceNse oH lyll�89 . . . C�ass (commencing with Section 7000)oi�ivision 3 of the Busiriess and P� REG.NUMBEft �C+—�0 - Pro(essions Code,anA my license is in full force and et(ect. Powe�ApparaNs&Large Ap0liances D�siAiCi uo. aROC,�(EySS�E�BY Size 8 7ype HP,KW,KVq,ar KVAR Q 1�14� . `., Ucense Number 422589 - ��.ciass �-10 uP to�i mci. ...- . . Fi�A�. �.. .... . . .. ZS E & D ELEC ..� - 7 Over 1 ta 101�1. �A� 3f LY, VALIDATION � Contractor Date � pver iD to 5D Inct � � FINAL U � 1 am exempt untler Sec. Over 50 to 100 Inc. gy. _ {a,I B.8P.C.lor Ihis reasan Ovcr 700 (L Services,Sw6tl..MCC 8 Panelbaards-- � � � ,- - � - �� . � � � Date: 0-200 Amp.U�der 600 V . ^ Signature ' 201-1 D00 Amp.Under 600 V � �-' - � �� � o�er t00D Amp.or o�e�soo v �0 9 7,b A Exemplion For Reg.Maint,Elect �'r-. o C - _ J^ � SINGLE FAMILY- - - � Temp.Power Pole&Appurtenances � • � U 2.� �l . HOME OWNEF-BUIfAER DECLARATION Sign wilh One B�anch Circuit � � � o � �G 1�l c=> " I nereby afllrm that t am exempt from the Contracmr's License Law Additional Sign Branch Circuits Por the following reason(5ection 7031,5,Business ana Pmfessions� � �� � � O p C 4"S�I � Codc): ❑ �.as owner ol the property,will do the work and the sUucture �'A'sa Conduits 8 Gontluctors � - � � - � is not inter�etl or oilered for sale(Section 7044,8usiness O[her(See Complete Fee Schetlule)_ , and Pm(essions Code). GONSTRUGTION LENOING AGENCY - - - � � - - � � I here6y affirm ihat ihere�s a construction lending agency for the performance ot the work for wnlcn Ihis perma is issuetl(Sec.3097, pgpMlT FEE - - � (Sub4olary 131 64 ���� � � � � - � - - � Civ.C.). � PLAN CHEGKING FEE � � � �� - -� Lenticrs Name _ PERMR ISSWNG F[E ... . ZO O _ , . . . . Lendcr's Atldress . 1 cer[ily tha�I have reatl ihis application and stale that the above TOTAL FEE ].L{2.].Lt _. , _ _. .. . , i1110fmatlon IS COffECt.I flQ/E2 t0 COlflply W�th A�I GW�ty Ordin�tt�es , antl State laws regulatin9 Electrical wiring,and hereby authorize _ _ . ' _ _ _ . representatives of this County to enter upon the above-mentioned � - per o inspection pur0oses. ,_. SEE REVERSE FOR EXPLANATORY LANGUAGE . . . ... . �.�lL 4�-[�'-��-- _ . _ Slgn pate . � � 1 i. ..M .v . ... .t. ..:'. . . ., . , . i . . � .,. .. . . � ' . . . �. . . . . � � , ,_. Ac n ,,_. _. ?JJ�.. i ... ., __. . _ __.. __.____ _.---,- -__.... ...__.. , ---------' - � � � �-- ��� ,'" ��APPROVALS � �.. ,� - DATE �- INSPEc;ip frS__�,. _ _. ' - �-�� ��O`NNER-BUILDER DECLARATION '� - � �:��. .�: J. " �i SIGNITUF� ._.__.. _._ . . .. � 1 � . � �.. �,,�- 7EMF.PO\4ER PbLE . . �_�_' . _,,�..�. .. , ; � - - I hereby atfirm Ihat I an esempt Irom Ihe Contractcr's Lieertse , : . . . "�:'. ' �.� „ � ___.__. .. . __ '__ 1 : . . ..:� . �, •. � '- . � .. �La•n far thc tollrnvin � . 9�eason(Secfon 7037.5,Bus�ness and � UN�ERSLAB N/ORK � .. '.-. .-- - :. ._..._'___' ' '....._. '. . .. Pro�essiqns Codc):Arry eity a�Counfy whieh repuires a permif � -�� -�� --�� - �-���' .'�to corub��ct,alte{hr�;rove,demolish,a rep,air any.slrucGxe,pria � I ��_,_ ... FOUGH CONDUIT ..: — __ . . .. _ .__. .�. . . � � _ • ���� ! �-�"�""to its fssuance,also requires ffie&,opfiean(�a such pe�mit lo!i!e ; -„ .WIftING�. ,- '� �. ' . ___ ,_._� ��,__ � P sgned Statemcnt that hc is licen;cd pursuant to thc praiisions - � �`� � � � ��� � , o!tnc Cont�aeta's�Llcensc Lrnv lChaA�ei 9 lcorrnmcneing wrth . _._ __� _ . __... .. _. . _. .. . - , � FlXTUFES . � _.._ . ..__. _ ..:__ ._ .; . , � ,� _ . . . - . �- ��Secfion�7000J of Divfsim 3 0!the Bus�»ess anA Prolessiw�s --- -- - �---� UTOIIJTY-CO.N30TIF1ED � �'' '. . .....� � �....�.- �� � i �el or�thol�he Is'�excmAt fheretrom and tbe 6:c;is/a'�thc 1 � � � ��a!leged exempiar.-Any vinlaticn ol Sectiwv 7031 5 6y any 1 � ' � � appt�can tor�a pc�mit subjecfs fhc r.pA�icanf�lo a civil prna�ty :—--��- '-- .'-'--------- -RNAI. ..---� ---ryT(CT'OIt FT'0)Il ' � . . � � ' of rrot moro than/ivc hundred tloVars(35001:� - � � __..___._NOTES__.__, � ' ' ' � -'�'-� - ' % ❑�,as owner ol thc property v�ill tla Ihe��rork,and the ---�-- -.—.- .-_--. ..�' . .. ' . structure is rat intanded or offered for saie. -.- � .� . . . ..;.'. . _ . . i ... .� , ...,.. .. - .; . . ._ � ; . I , .. , . . . � � ! � (See.�044,B�rsiness and Professians Coda�7ne Contra�._s .... ...__ '__—_ _�. . (_. . _ . . � , � Gicense Law c'oes na appry to an aM1ncr ol p.�q�erly who 6oiVCs � ._._____. _'___' _�_�_�_...�- __. '�. '�� . ' ..... .,: ... �..��' . . i . �a imP�s Eherea�.and who�docs SUCh vroik himse!(prcvided . . . , � Biat such imp�wements aro not inMntled a oflereU tor sale.11, ..�_, � . � ., � . � ._ : >.. ..._.__.___.__ ' _ �_ . � ; , � .__ �-. . . :. � . " � howeveG Ihe bui7d.n or Im -- .-- �g prove,�nent!s satp'wim.�n onc year o1 -'' " ' �� . .. � ` �� eompletion,the rnvxr-builder wilf have ihe burden ol proving fhaf u....__._ _.. ,___..___._...._.�.. .�._.'_.� ._ . i . . . . , .,. . . � �. � he did no1 bmld or u�prove Iw the pu,yose of sale.J . .. , . � _. . � 1 - •i � � . . r '�� P,- . . . . .._ �_` .. -..t. �'. ' .;� , � "'" ' " _"__'"._."_'_.__ . , .. : �..i_ , . . i ',.: . i . .._ ._ . . .._._ . . .. . . � " .. .,- „ , , �. , . . . . _ _'_'_._._ _. ....._"_' : . . _.__ t _ "'. . ... � .......... .�. • . �....�� �� � � . . . . .. .. . �. . .� :.. _. ' -�__...._ .. .. __.' - .-- - --��� , � - --- � �,� =7 am exempl:untler Sec. ..,, i.., , . .. . - . .� . . � .. . . . �. : •. . � �.. _ _ . .. . ... ..-` - ----..-. -..- . ----' �. . .� -__.._. .. � ,-� � . . i-� , --8&P.Q For this reason . i __. ..._... . _._,__.. _ , ,I.. ; . . . , .. � ...Date.. _.. __.. ..... ._. .. . 1 . � . - , Owner .. . � � - . . . � .� ; � ' ... -�- '�:: ,. .�, . ��,�. .. . , . ..___ '�._. .__� � , . . . . ��._.'__....... ' .. , ' . , . . ... � , � , � ... ...___ _. ..._..... � � - _ .. . .�.. ___._ ._.._--�--� � . ',.,'. �. , : , . .� . . . , .. . , . � _. _. _._.._�_ . __. ___i_._...._--.___.__. __--_.._:_ .. , + �___. _--.�'- - ._..__...—_--'-'..___—.-'_------- . ,. 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