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Home My WebLink About1653A _ , � WORKERS'COMPENSATION DECLARATION �� 8� APPLICATtON FOR ELECTRICAL PERMIT � I hereby affirm tho� I have a mrtifim�e of consent to sxlf CE-BiDM' , insore,or a certifica�e of Worke�s'Compenwtion Insoronce, CpUNTY OF LOS ANGELES BUILDING AND SAFETY or a ceriified copy thareof(Sec.3800,Lab.C.) - � P�olicy No. Company iOR AAUGNT TO fltl IN � JOB Certifiad copy is here6y furnishad. New Residen�iol Bldqs.8 Pools �� FEE ADDRE55 21378 Broken Arrow � Cerrified copy is filed with the counly building inapec- 1 8 2•Family,Sq.Fr. f — f LOCAl1TY �amond�Bar. t3EARE5T ro�deuo��me�r. re�u;-romnY sy.Fr. — caoss sr. P thfinder & B Dafe Applicant Residen�iol Swimming Pools ��R� FIRMNAMEGI'C$t W88tCTA SdV1II S CERTIFICATE OF EXEMPTION FROM WORKFRS' Outlets:Rec_light_Sw._ �`�� COMPENSATION INSURANCE F.5'p nooaEss • ' 132 8 (Thb��Nfon n�ad net b�compl�hd if fh�work invelv�d b� �Total No. Addi�ional cirv Northrid e CS. Tel.No.2]3 'jOI.–H SO th�p�rmN ts for on�hundr�d dollan(3100)or 6u.} .. I cenify fhot in the performonce oF the work for which this aPM�CAN7K � permit is issued,I sholl nof amploy any person in any monner so as lo become subject to Ihe Workers'Compensation Laws. li9hting Fixturas Firsf 20 ADDRE55 � Tofal No. Addltional -Do�e2�20/84 pPP��o�� J. R. Elect. Co. GTY .TeI.No. NOTICE TO APPLICANT: If, affer making this Ca�tificnle of Fixad Appliances No�Over I HP PERMIT Exemption, you should 6xome subjec� lo Ihe Workers' Range_Heo�er_D.W._ APMICANT J. R. Elect �.O Compensoiion provisions of rhe Lobor Code,you musi forrh- Oven _Dryer _W.M._ ADDRESS 633 W. Katella Unit-L � wifh comply wifh svch provisions or this permit shcll be 7op. _FAU —W.H.— � daemed revoked. � Hood _Fon _Other_ , CITY Oran e Ca. tei.rio.�14 538-2 48 LICENSED CONTRACTORS DECLARATION UCENSE OR I hereby offirm thm I om licensed onder provisions of Chopror 9 Disp. _Room Air Cond. — REG.NueneEa CI s - ' (commencinq with Section 7000)of Divisio�3 of the Business DIST ICT NO. OCESSED 8 ond Profeuions Code,ond my litense is in full force and affatl. Powar Apporatus 8 Large Applionces .. � . 6 Size 8 Type HP,KW,KVA,or KVAR� Q license Nvmbe� 4�067 Lia Closs C'10 �P�o��; FINAL V Conlracror ,T R Elect C.aDote 2�2��84 Over 1 lo IO lncl. DATE,Z�2Z'�i1 VAUDATION Q `T OOver IO to 50 Incl. FINAL t~j I am exempt unde�Sec. Over 50 to 100 Inc. 8Y � 8.8P.C.lor this reoson Over lOD Z Dale: � Servicn,Swbd.,MCC&Ponelboards � - - 0-200 Amp,Under 600 V � SignaNre 401-1000 Amp.Undar 600 V � ' � ❑ Over 1000 Amp.or Ovar 600 V Exempfion for Reg.Moint.EIecL � � �j SINGLE FAMILY Temp.Power Pola 6 Appunenances . . . HOME OWNER-BUILDER DECLARATION Sign with One Broncb Circuii . I hereby offirm that I om e.empt from the Contrador i license qddirional Sign Bronch tircuits Law for�he following reason(Sec�ion 7031.5,Business and - � � Professions Code): . - ❑ I,as owner of�he properry,will do the work ond the M�sc.Condoiis&Cond�cmrs g} 6 5,3 a_ struclure is not infendad or offered for sole�Settion O�he�(See Compleie Fee Schedule)_ ► � � �,. 7044,Business and Professions Code). �r• • L CONSTRUCTION LENDING AGENCY � • °2 S�5 O � I hereby offirm Ihof there fs o consfruction lending pgency for � � the performonce of Ihe work for which this permil is issued PERMIT FEE �(Su6•Tofal) - . . , •2 J.5 n G (Sec.3097,Civ.C.). � PLAN CHECKING FEE - . d 2'2 1�B 4 Lender's Name � ' 1 PERMIT ISSUING�FEE 1 O - lender's Address ' � I cartify that I hove�ead this opplicalion and slale Ihat fhe TOTAL fEE � a6ove informotion is mrtad.I agree ro comply wilh oll Counly ordinances and S�ate Iaws raguloting Electrical wiring,ond hereby authorize rapresenta�ives of this County to enter upon � � -� the obova-mgn�ionad proper�y fo�inspedion purposes � . SEE REVERSE FOR EXPLANATORY LANGUAGE -�-w-..^tc- .�. � � Signot e of Permillee pte � E . .. - � � - �� . � OWNER-6UILDER DECLARATION . ..._.. n � .'....'APPROVALS DATE � . . . . . . . � . _. _ SIGNATURF .-_ .. .. . � TEMR.•POWER POIE - � � � ' � I hareby affirm thor I am oxemp�from�he Controctor i � - � - - ' � • � -. 4�cense low for tha following reason (Sec}fon 703I.5, - . . rl��, _ US1DE$SLAB.WORK � _ . . _.. , - �, BusMessondProfasslonsCode):Anycityormun�ywhlch ' � . FOUGH CQNOUIT � - � raqvires a permR fo construcf,al�er,Improvc,domofish. � � n-Iv - . . � or rvpo4 any shutlme, pNor to Ils Issuanro. afso ro- . � WIRING _ , . quireslhoapplleanHorsuchparmlftailleaslgnedsfalo- � "-� .. . .-'•T'_ .. . � � � � meM thot ho Is Iiconsed pvrs�onf ro tbo pravislons of Ihe .. ' ... FIXTURES, � . Contracfor's Uconso Lcw(Chaptcr�9(commonclnc�vdrh - - POWER AUTHORIZED - � " - � �� Secflon 7000)af Dlvislon 3 0l Ihe Euslness ond Profes� � ' sions Code)or Ihol ho 7s exempf fherofrom and Ihe basis - -� - - � � - UTIIITYCO.-NOTIFIE� � . for the.olleged exempfion. Any vlolaf�an of Secfion � - - - -- FINAL n c7 � 703I.5 by any oppllmnf for a permR sobJects fhe oppli- - - Gnfcr ok .lrortl _ � cont}o o clvll penolfy of nof morn fhan fivo hundrod . . . . . NO7E5 � . .. . - . dollafs'(5500).: . . : , .. � . _ - � � � � ❑1,os owner of Ihe property wi�l do tho work,and -" -""" - � � � �� Iha st:utlore Is not intended or aPfercd for salo. � - . � 1:^ . � '�r � . � (Sec.704�,Bus7nossondProfesslonsCode: TheConlrac- � �� -- for's License Law doos nof opply fa an owner of property . . " . .. . .._ .. . . �" - � _ � � who bullds or Improves iherean, and who does sueh work himself provlded fhat such Improvemenfs are no� � ' � � � � - ' ' - . Inlendod or otfered(or sole,If,howover,1ho building or ' Improvemenf!s sold wHBIn ono year o!completion,the --. � . �. 'owncr-bufldorwillhavetheburdenofprovtngihafhedid � - � not,bvlld or lmprove for ihe puiposa of salo.) ' � � I am exempt under Sec. , -. . ..__ . . � .. . . � . . _..- � � .; �_. .. . � B E P.C.for this reason . . . _ . . . � � . . .Date � _ � Owner � __.. . . .. .._ . . . _..