HomeMy WebLinkAbout1748A (10) WORKERS'COMPENSATION DECLARATION �eA�� �o.B� APPLICATION FOR ELECTRICAL PERMIT �
I hereby affi�m tha� I have a certificate of conseni to self CE.BmG
insure,or o cert�ficate of Workers'Campensa�ion Insurance, � COV�j V F L4$ANGELES BUILDING AND SAFETY
or er fied(c�oc(y.yt xg�of Sec.380D,lab. ) � eL
� � `vv�v qX FOR A►►UCANT TO Rll IN JOB
Paolicy No. Com�any� �.�
Certif�ed copy is hereby 4urnished. New Residential Bldgs.8 Po Is EACH NO. FEE AD�RES ��
� Certified copy is filed wilh the counly building inspec- 1 8 2-Family,Sq.FI.� s — S ����ITY
tion deparlment. � Mulli-fomily Sq.Ft. — NEaRES�
c� � P ��'�� Residential Swimming Pools OWNER OR )
Do�e�� ���'X�pplicant - FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Ret_Light__Sw._ � ���
COMPENSATION INSURANCE AD�RESS ~ '
Fint 20
� (Thb��cf{on nNd no1 b�compl�f�d i#th�work�nvolv�d by Tatal No. Add�tfanol CIN � Tel:No.
th�p�rmif b!or on�bundr�d do�lm�(SI00)or I�ss.) PtAN CHE K a^'1' �/..��5
I cerlify Ihat In the performance of ihe work for which this APPLICANT I C�
permit is iswed,I sholl no1 employ any person in any monner
so as lo bemma subjecf to the Workeri Compensa�ion Lows. ligMing FizNres First 40 ADDRESS
l ioral No. Addi�ionai
Da�e\�"`�pplicant ����� CITY Tel.No.
�.r� Fixed Applipnces Not Over 1 HP PERMIT
_E TO APPLICANT: If, afier moking this Certif�ca�e of ApP�ICANT
,ption, yo� should become s�bjett to �he Workers' Ron9e_Hearer_D.W._
Compensation provisions of the Lobor Code,you mus�forth- Oven _Dryer _W.M._ ADDRESS
with camply with such p�ovisions or ihis permit shall be 7op _FAU —W.H.—
deemed revoked. Hood _Fan _Oiher_ CITY � I IVo.� 'Z���
LICENSED CONTRACTORS DECLARATION UCENSE OR 1�
I hereby aHirm that I am licensed under provisions of Chopter 9 �isp. _Room Air Cond — REG.NUMBER 1 �`�� Clou.�-C'� }
(commencing wilh Saclion 7000)of Division 3 of fhe Business POwe�Apparatus 8 Large Appliances DISTRICT NO. PROCESSE BY O
and Professions Coda,and my license is in fui�force ond eHect.
p n Siza 8 Type HP,KW,KVA,or KVAR U
License Number��,5���d lic.Ciass� Up to 1 Ind, FINAL - �
�� (�'�� ���S pOver 1 to 10 Incl. DAiE A/�� ypUDATION U
Contractory.�--��� Date 1���-'�'o� �"Y
� Ovei 10 to 50 Incl. FINAL W�
I om exempt under Sec. Over SO to 100 Inc. BY
over 100 - :} %Li.�?R �
B.SP.C.for this reason � Z
" Date: Services,Swbd.,MCC&Panelboords , �-' . < •2
0-200 Amp.Under 600 V • e
Signatore 201-1000 Amp.Under 600 V � • � � F tl 2
OOver 1000 Amp.or Over 600 V o
Exemption for Reg.McinL Elect. ` � � ���� =
SINGLE FAMILY Temp.Power Pole 8 Appurtenonces '� f� 9—�F
�^"�, HOME OWNER-BUILDER DECLARATION
i Sign wiih One Brpnch Qrcuil
1 ry affirm that 1 am exempl from�he ComracroPs License Addnional Sign&anch Circuits '
� Law tor the following reoson(Seclion 7031.5,Businass and
Professions Codey: . �
❑ I,as owner of the property,will do the work ond the M�sc.Conduits 8 ConduUors
structure is not intended or offered for sale(Sect�on Oiher(See Complete Fee Schedule)_ ,
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY �
I hereby affirm that ihere is a constroct�on lending agenty for
Ihe performance of the work for which ihis permir is issued pERM1T FEE (Sub-Toial)
(Sec.3097,Civ.C.). �
PLAN CHECKING FEE � .
Lender's Name �
PERMIT ISSUING FEE � J Q
Lender's Addren
I certify Ihot I have reod this applitalion and slale thot ihe TOTAI FEE � f 2 '
above in(ormo�ion is correct.I agree to mmply with oll County ,
ordinances and Slme lows regulaling Elec�rical wiring,ond ,
herehy aulhorize representalives of ihis County to enter upon
Ihe above-men�ioned property for inspet�ion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
�IY1 �a�e�,� � Z ,l G��
Signolure of Permiflee Date
. .. . _. . _ _ . . , �.< � . ...-�.�.. � ER6U U TIO
� • , n�aKOVatS , D�TE. ` ' �. ,'OWN� - ILDER ECLARA N .
' S1C3NATUk'E.�. ... '... . . .
, __.. . __._. _ _ _..
. ""` - ' - � � TE.".P.POVJER FOIE. . -� - � � - '' � - � � ; I horcby atfirm 7hdt I�am azemp�from tho Contratlor's
� __ . , ' ._ � � . . �, . Licenso Law for the following reason (Section 703L5.
- � .....- � . _ ... .. UN�ERStA➢YJ02K� - . .� �
_ � � QvsinossartdProlesslonsCode):Anyc(fyortounrywhitA
- ROl1GH CONDU!T-� � . ' � � . �, �_ � . � re9vlros a�permll fo cansfru[f,oficr,fmprove,demolish,
�. � �� i -""��- - - ' . • � - -br repalr any s)roclure, prlor 4o i/s Issuance,olso re-
-� � ' - � YJIRIpIC- ��-- � � �/���- � qulrof iho apFllmnt/or,aucfi permll!o fllc Q s�gned sfalo-
. � . . �.. ' FIXTUR�S - . � -� ' menf Ihaf hc Is flconsed pursucnf�o tho provisions o!Ihe
- ---� � � ' � �' . Conlracfori Llcenso Low(Chapter 9(commencing wlih
PO'NER AU7HORRED.. � � � -� - - - � � ' -- �' - �"�� � Section 7000J of Oiv/s(on 3 e(fbe P�siness dnd Proles-
� _ - . " slons Codo)or fhot 6v Is exempl Iherelrom ond!he basis
-_ UiILITY CO.NOTIFIED � .,for !ho vflegod oxompffon.Any vlolotion of SecHon
FINAL f' c} �- � - �� � ' . . .�7031•5 hy any appllconf Io�a permlt sub�ec�s tho apph�
. .. . . (�n�c�oa .��onf can}fo a Nvll penolty of no�morc Ihan fivo hundred
___._ __. .. _... . . . .
`� NOTES -" � - � , dolfars(55001,: ' . , .
- --- �� -. � ' � ' � - ' ', , j]I,as-owner af rha properry wrl!do ihe wori^'•d
' � � � fho SVucturo is no�intonded ar of(ored for sole.
. � � ' � . � . _ . , � (Soc.704<,8vstnesa ondPro/osslons Code:_ihe Controc�
� � ' ' - .�or's Uconee iaw does not cpply fo en owner of properry
'� . _ � ' . � � � . who 6ullds ar'improvvs fbereon, nnd who does such
-- - - - �- -� - -� � --� " work himse(f prov�dod lhot 3uch fmprovemenfs are nct
� '� � ' - �- -� �� - ' � � --- � �� �infended or o/(ored for tole.!L howeveq Ibv 6ulld�ng or
- �� " � � � � lmprwem�nf fs sold wifhfn ono yoor ol compleflon.1he
' � � � � ' ' ��owner•bW(der wlff have Ihe bwdon cl provfng fhathe did
� ' �' ' nol bulld arlmprove lor fFv purpos-ol zafo.)
. � . _.: _.... � . _ -.. ._ ' ,
'� ' '�'�� I am axempt under Sec.
;� � � _.. ., . �_ :. _ . ._ �... �--�--��- - ' � �.
� . ._ _ .- - - . ,
, . .. . ___ B&P.C..fcr this rcason. � � �
.. . -i __ __ . . , .
..,-- -_ . . .. � ._. Date_ . . _. .
� - ' , . Owner ' � � . . � � '
. _. .. . . �... - i ..,� � . , � .. , � . . �
.. _., . ._ ... .. _.... .. . .-' . —_" . , . " , , : . . . , ,
... ...1. . . , - . ,