HomeMy WebLinkAbout1742A (10) WORKERS'COMPENSATION DECLARATION 76A663 10/61 , APPLlCAT10N FOR ELECTRICAL PERMIT ry'
I here6y affirm thot I hove o[erti(im�e o(consent lo self �E-�' �
fns�re,or a certificate of Workers'Compensarfon Insurance, [� T QF LO GE�E$ BUILDING AND SAFETY
�o fer[ili��pqy�r�of(Sec.3800,La .) �
1n lv�J�a.,b FOR A7►UGNT TO Flll IN JOB �
�c��r�ro. Compan
Certified ro s hereb furnished. EACH� NO. FEE ADDRE
py i y New Residential Bldgs.&Pools
1 8 2-Famil 5 FL E — S IOCAIRY
Certified copy is filed wi�h 1he coomy building in5peo �� q' NEAREST
tio de tmenl. n Mulli-FamilySq.FI. CROS55T.
�`t �n Residentiol Swimming Pools OwNER OR
Dore Appl�can�`�f Q U iIRM NAME
CERTIFICATE OF EXEMPTION FROM WOI2KER5' Ourlats:Rec�ligh�_Sw._ ���
COMPENSATION INSURANCE nDDRE55 I . /
Firsf 20
(Tl�ls:�Nlon nNd no1 6�campl�}�d H th�work Involr�d by Totol No. CIlY Tel.No
th�p�rmit Is!or e��h�nd��d dollan(5100)or I�s�.] Additional p N CHE K
lA
I cer�ify�hai in the performance of the work for which this APPLICANT
permit is issued,1 sholl no�employ any person in ony manner
w as to become subject to the Workers'Compenso�ion Laws. Ligh�ing Fixlures First 20 �4DDRESS
Totol No. Additional CITY Tel.No.
Do�e Applicont Fixed Applionces Nol Ove�1 HP
p��-'�TICE TO APPLICANT: If, aNer making ihis Ce•�ilicnte of A�tI�CANT
� �ption, you should 6emme subject 10 Ihe Workers' Ra�9e_.Heoter_D.W._
,npenwtian provisions of ihe lpbor Code,you must(orlh• Oven _Oryer _W.M._ A�DRESS �
wiih comply wi�h suth provisions or this parmit sholl be Top ._FAU —W.H._--_ C�T Tal.No. a.1
deemed revoked. Hood _Fan _Other_ 1
� IICENSED CONTRACTORS�ECLARATION IICENSE OR
I here6y aHirm Ihot I am licensed under provisions of Chopter9 Disp. _Room Air Cond. — REG.NU�uBER Closs }
(commencing wiih Se<tion 7000)of Division 3 of rhe Business DISTRICT NO. PROCE BY Q,
ond Professions Code,and my lic nse is in fuU iate and effed. Power Appara�us 8 torge AppGances � p
����/''� Size B Type HP,KW,KVA,or KVAR V
License Nomber Lic ClossL-Ll1_ Up to 1 IncL FINAI �a
Over 1 to 101ncL �ATF ��,r� -� VALIDATION �
Conlroctor��i�-� Date �� '4 U
❑ Over 10 to 50 IncL FINAL :�.� I Q L F w
I om exempf under Sec. Over 50 l0 100 Inc. SY � � ' �
6.8P.C.for this reason �ve��� t� ' �� . Z
Dote: Sarvices,Swbd.,MCC 8 Panelboords ► - � • � �7,(��
. 0-200 Amp.Under 600 V
� SignaNre 201-1000 Amp.Under 60p V • ^ � i!.U.�.�u
OOver 1000 Amp.or Over 6pp V
Exemp�ion tor Reg.Maint.Elec1. � G� C/—`a Jr
SINGLE FAMILY Temp.Power Pole 8 Appurtenancas
�` HOME OWNER-BUILDER DECLARATION Sign wilh One Bronch Circui�
I by affirm Ihor 1 om eaempt from the ControUor's license qdditional Sign Bronch Cirwils -
L or ihe following reason(Section 7031.5, B�siness and
Pratessions Code):
❑ I,as owner of ihe properfy,will do the work ond the M;sa Conduits 8 Conduclors � _
strudure is not intended or offered for sole(Section O�her($ee Complefe Fee Schedule)_ ► � �
�044,Business and Pro4essions Code).
CONSTRUCTION LENDING AGENCY
I hereby aifirm thq�lhere Is a construcrio�lending agenty for
fhe periormonce ot Ihe work for which this permi�is issued PERMIT FEE (Sub-Totol)
(Sec.309�,Civ.C.).
PLAN CHECKING FEE � -
Lender's Name � 1
PERMIT ISSUING FEE � �
Lender's Add�ess �� _ ,^
I cerliFy fhat I hove read this applicotian and state Ihpt the TOTAL FEE �V
obove information is mrrecL 1 agree to mmply with oll County �
ordinonces ond Sio�e lows regulaling Eleclritol wiring,and �
hereby au�horize represen�o�ives of Ihis Counly fo enler upon
he above-m ioned property(or inspec�ion purpos s. �
SEE REVERSE FOR EXPLANATORY LANGUAGE
` � .�4Rf� l c3�1��l �
S�g�a�ure at Perminee � te .
_. . ....., __._.., S�CNATU .. . : � :.�.. � .�` '.... ' . . ,� .. .. ...
' : � , APFROVALS . DFTE "` "'" . _ _ , . ,O NER-BUIL�ER�ECCAF:ATION .
RE
. .-.- .. . . � . TEf1.P.POYlEP,PO:E. . . -- . .. . . . . . . � � �' ' I here6y affirm'16at.1 am e empf from thn CoNracto%s
,_ . .._ _ . ' � � . . . license�Law for �he followiny reo:on (Secfion 703I:5.
�'... ....... ..... . . � . . UND£RS:ABVlORK . .
� . , , , . , 8osinns;mdProfesslonsCodeJ:Anycl�yarmuntywhkh
�� �--� - ��� - -- �---- £OUGN CO'1�7VI7 � . . . . . - -� � � � reqV%res operm7f}o tonsfrucf,alMr,Improvc,demo��sh,
. - � ---�or repulr ony�struc/ure, pr(or�o�llz•lssuanco, also re-
- - - - -- -�-— �� �� WIRING ' � � /F"� l>� , qWrexiheapp6:onfforsuchporml!fof�leas�gnedsfofe�
_. . .. . . _ . FtXfU�c'S � � - - . _ , � mcnf tAct he Is f![ensed pvnUant to fhv p�ov(sfort:ol Ihe
-. - . � Confrocto�i Uccrtso Lrn(Chop�cr 9(commenUng wifh
�� ..' '. _� . _ ... . POl"JER AUTHORI2E� - - - - � � � . � Sonlon 7000)af ONtslon 3 0!Ihe Bus�ness artd Prole;�
, .. slant Codo)or Ihaf ho Is osempl lherefrom ond Ihe 6osis
UTIIITY CO.NOTIFIED � � . far.Ihe al/nged ozamp�ion. Any vlofctian of Secfion �
�_. ... ..._ . . .. �. .. FlNAL n � c7 - . � .., -. 7C7L5 6y any applitanf lor a permlt subjects�he appl�- .
_.._ _. _. .... ..._.. -Gnler en y�ronf . mr.1 fo a elvU penolfy of not more lhan 1No hundred
� � � � � NO7Es � � . - -. . dolfors(5500J.: . � � �
._. . ._. `..__ _. . _._. . _ . . �. . , . . . _... .
. � • � . .�I,os owner af tho prcpony will do)ho work.and
- '� the sfructure is not intc,nd�d or offnrnd fo�sale. �
- . � � , - . � . . .. .. � � � � (Sec.704d,0usinossandFra/essionsCode: TheCo�. .o
� " � ' '"_...__ _�� --- .. . � �for's Uronsc Law dces noi opply ro an awner of propvNy
� . • . �� � . .,. � who buifds or�lmprovrs ihoreon, and wBo does such
. . ._. .. - - . .
� � �-� work bimsvll providr.d}hat svcb improvomenfs o�e nof
+��- . , ;' � ��� �� � � ��- �-� � � - �- - � -�� . � iMrndedero(foredlorsale.It,fiowever,ihebulldin2or �
' - �� � - � � �� •Improvemonl is sold wlfhin one year a1 complofion;tho
� - - � � . �� �'owner•�vlldcr will hovc�he burden of proving ihof he d�d
� � � � � � ' nof 6ulid or fmpravc tor thv purposo"of sale.):�
. . ... - . .. � � - ._ . - . ' --.i am oxemp�und�r Sac. - .
, .�. . . .. . .. � ..�.... . - � � .B 2 P.C.for this rodson � ".
_ ._. ..'_ . _ � . . . . .... �.Dove � .�. � .
Owner