HomeMy WebLinkAbout1743A WORKERS'COMPENSATIONDEC�ARATION 76A663 ,o.a��' APPLICATION FOR ELECTRICAL PERMIT �
I hereby affirm that I hove a certifimte of consenf to self CE-806G
insore,or o cenificate o(Wo�kers'Compensation Insuronce, CO TY OF L �IGELES BUILDING AND SAFETY
o�Seri'�qq ereof(Sec.3800,Lab .) f ti .
l4 J C�C7�
Policy�Jo. Compon fOR M�IKANT TO Flll W JOB
� Certified copy is here6y furnished. New Residenliol Bldgs.8 PooB EACH N0. FEE ADDRE55 ' _ -
�Cerfified copy is filed with the covnly bvilding inspec- 1&2-Fomily,Sq.FI. E — E LOCALITY
tion depailmenl. Multi•ipmily Sq.FI. — NEAREST
Residentiol Swimming Pools CRO55 ST.
Dote.�_Applicanl ��1�Q. . OWNEROR
fIRM NAME `
CERTIFICATE OF EXEMPTION FROM WORKERS' Oullels:Rec_Lighl_Sw._ � �"U`�� ' 1
COMPENSATION INSURANCE Firsl 20 ADDRESS ' ��' 1
(Tbb s�Nion nNd not 6�compid�d il th�work involwd by Tmal No. CIT Tel.No
fh�p�rmit la for on�hundr�d dollurt(5100)or I�sa.) Additianal 'Y1Q�
I cenif ihaf in the erformance of�he work for which�his 7LANCMECK
permit�s iss�ed,I shall not empioy any person in any manner APP��CANT
so as to become subjeU to the Workers'Compensotion Laws. li9hung Fiztures First 20 AD�RE55
Toral No. Addilional
CITY Tel.No.
Dote Applicanf Fixed Applionces No1 Over 1 HP PERMiT
���10E TO A7PLICANT: If, afrer making Ihis Ceriificate of '
ption, you should become subject to the Workers' Ranqe_Heater_D.W._ /+PPtICANT
�♦ �pensolion provisions of the Lpbor Code,you mosl foAh- Oven _Dryer —W.M._ ADDRES$ � '� �
� with comply wiih such provisions or fhis permit shall be Top _FAU —W.H.—
deemed revoked. C�TY � Tal.N `�— �
IICENSED CONTRACTORS DECLARATION Hood _Fan _Olher_
Disp. _Room Air Cond. _ uCENSE DR oss
1 hereby affirm Ihot I am licensed�nder provisions of Chopter9 REG.NUMBER� }
(commencing with Secfion 7000)of Division 3 of the Business power Apparmos 8 Large Appliantes DISTRICT NO. PROCE55 BY d
and Professions Code,and my license is in full force and affect. O
�1�",� /���� Sfze 8 Type HP,KW.KVA,or KVAR U
License Number �n�� lic.ClassL�LLL_ Up l0 1 IncL FINAL ' �
Q n Over 1 to 10 Ind. DATE ' O.
ConrraUor`-���-�• Date � `',�� ^R-b�� YALIDATION U
❑ Over 10 to 50 Incl. FINAL W
I am exempt under Sec. Over 50 l0 100 Inc. BY �,q
B.BP.C.for this reason Over I00 ir `� 7��r� z
po�e; Services,$wbd.,MCC 8 Panelboards , �i ° • • • •2
0-2W Amp.Under 600 V
Signatore 201•1000 Amp.Under 600 V � • � � �S.�2
❑ Over 1000 Amp.or Over b00 V � „F „V
Exemption for Reg.Meint.Elett. ° � � .
SINGLE FAMILY � Temp.Power Pole 8 Appurtenances I 2,� 9—��S
�� HOME OWNER-BUILDER DECIARATION Siqn wirh One Branch Circuii
I �hy affirm thot I om e:emp�from the Contractor's License Addilional Sign Branch Circuits
L or the following reason(Section 7031.5, Business ond �
Protessians CodeJ: �
❑ I,os owner of Ihe properly,will do 1he work and Ihe M;sc.Conduits 8 Conductors
structure is not inrended or offered for saie(Seclion Ofher(See Complete Fee Schedule)_ �
7D44,Business ond Pro4essions Code�.
CONSTRUCTION LENDING AGENCY
I hereby affirm ihor ihere is a construcfion lending agenq for
the pei(ormqnce of Ihe work for whith lhis permit is issued PERMIT FEE (Sub•Total)
(Sec.3097,Civ.C.).
, PLAN CHECKING FEE
� lender's Name ,
� PERMIT ISSUING FEE �Q
� Lender's Address �
I cerfify thot I hove reod lhis oppiicolion and slote ihal the � TOTAL fEE a
� obove informotion is correc�.1 agree lo comply wilh oll Counfy
ordinances and S�ofe Ipws reguloling Electrical wiring,ond .
� hereby authorize represenla�ives of this County to enter upon
%. the nbove- tioned property for inspection purposes. SEE REVERSE POR EXVIANATORY LANGUAGE
i �.7Y\e,.��4��_Q., \ �
Signalure of Permiltee pare
i
i.� _,
. .. , . ,
_ .---—. ....... . _ . .. .. .. -.-.�: . ..-... . W - UILDER DECLAR N
� , . � APaROVALS DATE � _ _ .. +�O NER'B ATIO
. , . -SIGNATI/RE �
' ' � � � 7E.".R FO�"IEF POIE. _ ' ��- � � ' ' � I horcby affirm that I am exempi frem�hc Contractor's
__._,_ . . _ ' - � licanse Lovi for tne followtng reason (Seclion 7031.5.
� -""--- �� - -" ��` �� UPJDERSLABV.'04K � � ' . , . .' ��, BvslnessondProlessfonsCode;:Anycltyorcounrywhich,
ROUGH LONDUIT - ._ � � " � roqu(res o porm�l to construn,akc�,improvc;demolish,
-"- � " - - or repo7rany shucluro,prlar!o Ifa Issvanco;-ofso re-
' , . _._ _. .. �'�. y��q��.i,g .' �7�' lji��a� � - qulrns tho applicont forsuch pvrmlt�o ftle o s�gned sta�o-
���� . � . FIXTURCS � � � - � �� mcot�hat Ac Is Ilccnsed pvrsuanf fo tho orov�sbns o/�ho
- - --� � . . Conlrocf�ri Llter.se Law(Chopfer 9(tommenUng wllh
� . POVJEF;�AUTHORIZE� -� - � - ��- --- ' "� � � Seclion 70D0)of DIv7s:vn 3 0l thn 8uslness ond Proies-
' �'�� "�' � -- . . sians Codo)or ehot he is exempi�hero/�om and rhe bosis
�. . _._,_ _ Uil!IN CO.KOTIFlfD ' .lor the aAegad oxompUon�Any v7olo�ion of Secl/on
FINA: �� Gnfr�an..Yrorf - - � . 7037.5 by any cppf'conl for a perml�subJecfs�he appG-
. . .. .. _ . -._ __ , , cont fo a clvl!penolty of not morc�lhon/ivo hundrod
� '' NOTES � � dofJars(35D0J.: � -
� - - -- - �- �'-- � - � � � ' � �. �1,as owner of tho properly will do thc work,snd
- � 1hc struUure is not intended or offc.ed for sole. � � �
� ._ , .. .. � � � (Sec.704S,8vslneseondProlcsslonaCode: TheCo.. .r
� � � ' - � ' �or's Uconso Law does no�appfy to an owner ol properfy
.. � � ' , who 6utfda or'Improvos ihercon, and who does such
� - � - � �- ---- - - - � - � -- ��- ' work himne!!prov�ded fhat such improvemenfs ore nct
�, . . ' . � � --- �- - �� -- � �" - fntended or olfered for sale.11,hawevar,the bulldiny or
' � - � ' "� � � � � ' � Improvemenl It sold w;fhin ono yeo�o�complelion,ihe
, � i �� � � � ownerbvfldcr wlll have fhe burden of provinc�Ihal he did
' ' � ' � ' � .nok 6u11d or fmprovo for fhe purposo ol sa1e.)
� .. - . _. .. - - - --- . � 1 am exempt under S�c. . . , - _ . .
. 6 8 P.C.fcr ihis roosort
� � - - -- - � � � � -- Cate_
O.vner