HomeMy WebLinkAbout1740A WORKERS'COMPENSATIONDECLARATION I6A669 t0i8i APPLICATION FOR ELECTRICAL PERMIT �
I hereby offirm Ihat 1 have a ceriifimtc of consent fo self CE-8061'
insure,or a certifimre of Workers'Compensa�ion Insurance, � NTY F L 5 ANGELES BUILDING AN�SAPETI�
�o–r–a/�fie.dr�roBy�h��reo((Set.3900,Lob.
Polk �4�`���Compan FOR AP►LICANT TO FlLL IN JOB
� Ceniiied copy is hereby furnished. New Residential Bldgs.8 Pools EACH NO. FEE A�DRE55 �C� � �
�Certilied copy is filed wilh ihe county building inspec• 1 8 2-Fomily,Sq.Ft. E — 5 LOCALITY
ti department. /� Multi-(omily Sq.Ff. — NEARE57
1' LQ Resident�al Swimming Pools OWNER OR
Oata Applicon� x •�
fIRM NAMEl ^
� CERTIFICATE Of EXEMPTION FROM WORKERS' Outle�s:Rec_Ligh�_Sw._ DDRE55 1 �-°1 ��
COMPENSATION INSURANCE Firsi 20
(This s�ction nNd not be compl���d if tl��work Inrolv�d b� Total No. Additional CIT Tel.No
Ih�p�rmit is for on�hundr�d dollan(5100)or I�ss.)
I certify tho�in Ihe pariormonce of�he work for which ihis A PNCC�NNTK
permit is issued,I sholl nol employ any person In any monner
so as to bewme subject�o tha Warkers'Compensation Laws. lighiing ii,eWres Firsr 20 ADDRESS
Tofol No. Additional CITY Tel.No.
Date Applicant Fixed Appliances Not Over 1 HP PERMIT
r"'�CE TO APPLICANT: H, after moking Ihis Ceriificote of APiUCAM .
�piion, you should becoma subject to �he Warkeri Range_Heater_D.W,_.
(.�mpensotion provisions of the Labor Code,yo�m�sl forth- Oven _Oryer _W.M._ ADDRE55 � '�i
wilh comply wilh s�ch provisions or ihis permit shall be Top _FAU —W.H.—
� deemed revoked. Haod _Fan _Other_ GTY, Tel.N .��..-.
LICENSED CONTRACTORS DECLARATION uCEN O
I hereby aifirm thal I am licensed under provisions of Chapter 9 Disp. _Room Air Cond. — REG NUMBER Class }
(commenting wirh Seclion 7000)of Divis�on 3 of ihe Business DISTRICT NO. OC SSED BY d
ond Professions Code,a�d my license is in full force ond effect. P�""er Apporolus&large Appliances �J U
Q'a(� (� �� Size 8 Type HP,KW,KVA,or KVAR �� Q.,Uyytta�
License Num6er ���-`v'–`� lic.Clossl�Ll.l_ Up t0 1 Incl. FINAL �
�/�1 — Over 1 l0 10 Incl. � DATE �7 ���� VALIDATION �O
Conlwctor��1�� Date 0. � U
❑ Over lO to 50 Incl. FINAL W
I om eaempt under Sec. Over 50 io 100 Inc. BY �
8.8P.C.for�his reason �ve`�� Z
Date: Services,Swbd.,MCC 8 Vanalboards ,
0•200 Amp.Under 600 V :_� %f�.C.(�
Signoture 201•100D Amp.Under 600 V �
❑ Over 1000 Amp.or Over 600 V, j� • • • e •2
Exemption fo�Reg.Moinf.Elec�.
SINGIE FAMILY Temp.Power Pole 8 Appurtenances � � � � �.�2
�.�, HOME OWNER-BUILDER DECLARATION Sign with One 8ronch Circuit
f by affirm thm I am exempt from�he ContraUor's license ' a � � r��=�
L� ror the following reason(Seclion 7031.5, Business and Addilional Sign Branch Circui�s
Professions Code):
� 7.� 9–�.I
❑ I,as owner of the property,will do Ihe work and the Misc Conduits 8 Conductors
shocture is not inleaded or of(ered for sale(Section Other(See Complete Pee Schedule)_ , ,
7044,Bovness and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby offirm�ho�there is a construttion lending agency for �
' the periormance of the work for which this permi�is issued PERMIT FEE �Sub-Total)
(Sec.3097,Civ.C.).
� PIAN CHECKING FEE
lender's Name /�q
PERMIT ISSUING FEE C�
lender i Address
I certify Iho1 I have reod Ihis opplication and siate Ihal the TOTAL FEE
' above iniorma�ion is correct I ogree to comply with oll Coumy
ordinances ond Sfale laws reg�lating Elecl�ical wiring,ond
hereby authorize represeMatives oi Ihis County to emer upon , �
Ihe abmve-me � ned property for inspection purposes.
� �r�/�\ SEE REVERSE POR EXPIANATORV LANGUAGE
h ��a �;S�.�.►(�"��L.��
SignatureofGermittee�' ' Da�e� .
,�ti
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._... .. .._..__, . .. .. . _ - .,-.. --�'� � - � .'O'vVNEP,-BUILDER DEQABATION� .
• . � � AFPP.OVA�S DATE.. arc a. _ � . . ._._ . .
SIGNA7URE- -- -
� � � - '-� '- -� �� ^ � � I here6y affirm fhc'I a exe�+pt�irom ih�Coniracro%a
� TE�J.P.FOWEF PCLE. . .. . . . . m
. . . . , � � � � Licento Law 1or�Ih9,followina reo:o� (Secfion 703�.5.
���' - - - - UNDERS,ABWORK� _ _ . , -� . EoslnessandProf�;slonsCodeJ:Anydryorcounfywh7ch,
�-- � � -- � --��" -�'- ROUGH COND'JI',�' . ' ' reqvlres e pormlf io tqnstrutt,v(�er,lmprovo,demolish.
� � � ��� or repalrony�ifrodure,pNor�fo Yts lssuanco, also rr�
- . - ��-� . �- � NlIRING � � - lf�� . _ qulret the opp!laanl for such perrntt to/Ile o s/gnod state�
' ._ . , . -.. -. 'f1�U2E5�- �. mcnl fhal ho ts lerens_^d pvrsCortl to tho provlsfons o/ihe
Confrarfor'a Lf.ensa tow(Chapfer 9(cemmencing wllh
� � ._ .. ' _ ... ... _. FOL"JER AUTHORIZ�D - � Secfion 70P0)o(Divla(on 3 0l fhe Business urtd Fro�es-
� � slons Codal or fhaf ho Is oxempl fhcrc/rom�ond�he basrs
_ __ ____ UTIUTYCO.NOiIFIED ., ./or }F�u Clfaged vxompf7an.�Any vlofction of Sec�ion
FINAL �� � . . ., 7031.5 by any appbmnf lor a permlt su6jects fho oppl�-
__ .- __ .. ... Gr.�u on �rorsf . �Q���o o dvil penaffy o!not mo�o fhon 11ve hundred
tioTes dono�5�ss�o�.:
� --�"--�� � - �-. �� � � � � � ' ' ' � � � ' ., ❑I,an owner of Iho prcperry will do the wcrk`�d
� � � ' ' � � � ' � ths struUure i:not intorded or offorod for sale.
- , . � _ . , . .. " � (Set.704a,Ousinees ondfre/esslons Codr. The Connac-
� � � �tor's LI[onse Lew does nof epply�fo an owrter of properfy
, � � . who 6ulfds or�Imorov�s fhareon, ond who doci such
' � � ' �-- � � - - � � - - �� � work hlmself provldnd fhc�such improvomenls are no�
.. - . - - � � - iMrnded er oflercd for salc.f(,'howoveq the bulfding or
� � �� � � � improvemonf�s sold wllAirt�one year o!comple�icn, the
. . _ ' � , owner•L-vilderwlll have�the 6v�den of prav7ng�fiof hn d�d
' � � � ' - ' no�6ulld o�improve lor ihe�vrpose of sole.)
:� � � - �� I am exempt under Soc. �
� . - i .. .. . _. � . ._ . . � ' . . . -- - - -- � � � , -. .
_ .B 8 P.C.for this reoson
. . _ . . . . . �Daie - ,
� � Owno: � ' ..