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HomeMy WebLinkAbout1554A (9) WORKERSCOMPENSATION"DECLARATION � 7dA663�� 1081 app`ICAT`ION �FOR EL�CTRfCAL P R� � �� ��1-� I�-(�ereby affirm thot I hove a cerhficate of consent to self CF806� `" . �� /� y �\{�7' insure,or a certifimte of Workers'Co ,,'.`.. .„� .,.,....,__,..._,,..,_ „„�_.,a ,„.„,..,__ _.�, .._� ,_ ,._,_�.,,._�..,.u,.,.�._... t_.�TWrs..<.� � pensa`tion��so�a�ce, C Y OF LOS AN LE BU(LDI G A ��� "c(e�rt�fi d �y t r f ac 380b}}}1a6,C/:1���-���� � -� _ �'- � '.y �,�� yTVo�-" ��mpOn����`�`� . �.:� . � ... FOR APPlICANi TO_KiCL;IN' .:.: . ... JOB . ._.._ ...,.. _,... . �._.. ._. - � Cer£fied copy is bereby fumished. New Residenfiol�Bldgs &Poo�s EACH NO FEE ADDRESS b� �Certified mpy is filed w th the counry building inspec-- �1&2 Pamily,Sq.Ft.��._S-a -- $ �d�A��T �� _ tion eparimeM. Multifomily-Sq FL .� - 'NEARE5f -'-- : ` --�� `�-� � �- ' '.� ��- / �� �y.d.�,.��,� - -Residentol�5wimm ng Pools � CROS55Y. � �at APPlicanG.�i14'.e2� � �- � . OWNER O .- .�.._, _-._. ,__ . .,_. _„ G �1 FIRM NA CERTIFfCATE OFEXEMPTION�FR6M WORKERS„� �__., �,� - -� - . MAIL --"-' ' --- � -�- . Outlets Rec_��_Light_Sw_ � � - ;.� C6MPENSATION"INSURAN�E _; ,�_�.. . ' . ti�DRe Q �.__„L 2 6� - . .. First 2D ._.. _.,.. . .'' __. . .._. (This sectiodneed not be completed f fhe work nvolved-6y � Total No. .:Add tional � � CI TeI.�No�?��_� - The permit is For one hundred dollars(5100)or less.j - -- - _ . . . . . . .. . , .. �I�ce'rtif tho+.in ihe -erformance of-the work fqr wh�ch this� � � . . P N- HECK. ,. . �:���-� . . ���� � . Y . - P . .. '- APPLICANT .�`permit irissued,I shall_nof employ ony person in pny manner _ - �� - � � _ .� - - - - -��- ��- so as io 6ecome-subjeci to 7he Workers'Compensafion Laws�, ��� ��qhting Fixiures. . .�Fiist 20 A�DRE55- - ...: - . ., . . . Add tional r � . ._.. _. . . ._. . _.. ,- = Tofal No. - ' � .� � CI7Y ' . . - � Tel.No. Date �` Applicant � �-- - Fixed Appliances Not OveF 1 HP 4� -PERMl7 " - - � - � ' NOTICE TO APPLICANT'.�If, after making this Ce�t ficate of � � - . . . � - - qppQCANT-� - � Exemphon,.:qou should�become_s�b�ect�to-the Workers' Ra�ge_-Heafer_D W — ( . ' . . -Compensotion prwision5 ot the Lpbor�Code;you must forth- -Oven _-Dryer —W.M- ..._,� - . - -� AODRE$'S? .�� � � w th comply w�th such�prov'vons or ih�s perm t shall be Top _�FAU —�N.H -.�� � - - deemed revoked,, �� .. - �Hood ._ �� - � QT '� iel.No.�,�7�, �, fpn Other � � .. _ � LIGENSED CONTRACTORS DECLARATION,, _ .._ — "'" "I �LICENSE R ��-- -�� ��""-- � � I�hereby aff�im ihat I am ficensed under provisions of Chapter9 --Disp. �Room Av Cond — REG.NUMBER fy�� '� Class � (commertcing wdh 5ecrivn 7000)oi D sion 3 of.ihe Bosiness - - DISTRICF NO.- ��" � - OCE ED BY - and Professions Code,dnd my 6certse s m foli force and effec�, _�-Power-Apparatus&Large Appl onces - i� . }� �" ' � -" C` - ' Size_8-�Type HP,KW,�KVA,or KVAR-� . � . - �-C/J-.-�� � Gcense Number����7� ��Lm.Class... JC�:.: .� - Up�0 1 IncL . -FINAL �-� - - V . . ���y�..M�+�� � . �J � ...Over 1 to 101nd.. . � DATE � L/CY�/ VALIDATION �- � �Confmcto ��•(. ate��J I�� . . .. '�' (� - -.. .... _.. ., ; _._.. __��..-., . -..,_�; Over 10 to 50 I�ci . FINAL � - - � :. �. '❑ I am-exempi under Sec _ . _. _�Ovet 50 to 100 Inc gY - . � . -� ,�,_�.��:'� . a B 8P C,for thrs reason - � �� .Over 100, _ ._. ' __ . � . .. �. H . - �- = � Se�vices,Swbd.,-MCC 8 Ppnelboards - � ►� - . . e a s w-e 7 � t , ��,e ` - o-zoo amP.under boo v � � » ; w�:1,4� Signature � � - 201 -1000 Amp.Under 500 V . . � - <.❑ :-.-: .' ` .-' . .-:- .. .,:. Over 1000 Amp.or Over b00 V--.- � � . � ^.� _. Exempf on for Reg.Mamt.Elect � � "�"`�'-'�"�'� ' SINGLE FAMILY �� _- _ iemp Power Pole 8 Appurtenances�. - - . U.'z,.i �.'_-t�L� � �� HOME CSWNER BUIL�ER DECLARAT(ON Sign w'th One B�anch Grmi) � -�I here6y afffrm that I om exempr from ihe Conhd�tar's`C�cense : qdd�honol Sign�Branch Circuits - --, Law for the following reason (Section 703L5, Busines6�and - �- . � � �- � - - � � -`. Professions Cotle):- � - � - ��-� �--� - - � � ❑ I,os owner of the properry,w II do�he-wo�k and tli,e �isc.Conduits d Conductors �_ � . structure is noi intended or offered For.sale (Section Other(See Complete Fee Schedule)_ ► : . _ �- 7044,"Business ond Professions Code). - � .. .'--CONSTRUCTION LENDING AGENCV- ��---� -- -� - �---� - - � �-.�-- ���- ��I herebq offirm ihat there is a consirydion lendinq agency for _ - � ��-�� � � --- . . ihe-performance-of the work for which-this permir�is.i�sued . PERIv11T FEE_--_ � �. . . _ . (Sub Totol) - � - . . �- ;SeL.�3097,Civ�.C.). � . . - . . . � . � '��-= �--- PLAN CHEGKING FEE .- - - � � � � � �Lender's Nome �__�_ . ..,. � � ��` �,. PERMIii55UINGPEE _�- �� .-.. : . ai `�+ . . ` Lender's Address � - � � - � � . . .� � ""'. " ...` TOTAL�FEE . .' F certify tha'-I have read th s application and_g}ate that ifie.-:, . . � .... . ... . .. ..Q.- � .. �-- above informat on s correc� I pg�ee To<omply with ail Coumy- - � - � -� . �� -- - - - � -- � - � "�ord noncesand Stote laws,regulqfing Elecfncal-winng,`�ond� -� - � -� - � -� -- � �� � � � -� hereby auihor ze representot ves of ihis Counry'io enter uparr� '"� " "` '-°"" �`�-` -� `-"�"' '"`-�` "�"`'- � � - - -� � �- `ihe above-ment oned property ior�inspection-purposes. � $EE REVERSE FOR_EXPLANATORY LANGLlAGE.. - � - - �,�, . _ . . � - . .. , ..._ __,__.. _ . . . _ .. i���_��„�.�' ���-���� _ __ _ _ �Sign ure of Permitlee.:_.._ ....-_ _ .Da�e __. �.._ , _�.�. :�, ..._, __.; ,_..,....:: .._:s:: ,,,,,;,,,,,, ,� ..;: . .,, .. _ ,� _. .,, __.. _ . ... __. � �_ � APPRQVALS �_. _.�..:6ATE �. 1� ... -. � -: : ..`�> ;" ... - _ � . . .- � . . LARATIOh � . �� OWNER-BUI DER DE'C � �� -� �-� . , SIGNATORE --S TEMP.POWER POiE� � I hereoy affirm that I om exempi trom�ihe Co��rccror's --- - - -- -�-- li<ense La�v.for ihe following reason (5oction 7031.5, � . . . UNDERSIAB WORK�..� . � � Business ond Pre`essians Code):Any rity or coun9y whfch � - - - �---��� � � �--�---� - � �-��-- - reqoires a permit to construc;,cL'er,imp�ove,demolish, � _ . ROUGH CO�IDUIT-- �� - - .- � or rapair any�sPrueturo,�prior to its issuence, also�re- .- ..., . . .�� WIRING - � -� - . . . qWrestheappllcar.tforsuchpermit?o#iteaslgnedsfete- �� �� --- ��� F;XTURES � ���`I � - -- �� - � ` � . .. . ment that he Is licensed parsuont to t6e prorisions of the . � . , . _� Contta[tors Licensa Law_(�..hCpter 4(commancing-with - �� - �- POWER AUTHGAIZED� � � - � � � � � - - � - � - Seciion7000)of Divlslon 3 ef the Busioess or,d�rcfes- � � srons Code)or tnal he is exempf fherefrom Qnd tfie basi> -`� � - ��� - -� � � . U7ILITY CD:-N4TIFiED� � � - � � � - � for�the�alleged exzmption. Any violation cf a'ection FlNAL �. - c� . . � . . . 7037.5 6y any applimnf for a pe�mif subjecis ibe appfi- � -... . ...�-. . ...�nEer att._.Y-rorsf .- .... - .. . - mnr fo a civll penaft}�of nof more than flve hundrad . . . . .__, , _ -..;_. _.< ..�.�_.,_.-,,..,..�,....,,�..�.-�;;.t�,,.�-.��....... .._,--...-._.. ..v-...:.,...>.�. :..�. -. -.,-. - ... .. ... NO'SES.- . .. . . . . � daifcrs(35Q0).: . . - , . �� �-- . - - � � �� _ .. .-��I,as owner of ihe�property will do the work,and - - ' "� ��� `��-� -�-� ' `-� � - - the siructure is no)intended or affered for sale. � . . . . .__..:�. .;,�... ,- .v .::_«.:.�>,.................�.,:.,-K-.�.,.�-.�-�-.,._,....�-.-...:.... _.....__.>._...___ . Sec: , us�nass an�ioi"e'ssions�o�;��TYi"e Conarac- � -� -�� -" � -�-- � -� ��- �--:. - tor's license Low does no4 opp(y to an awner ofproperty - . .., ` . .-..,-.< .,--:.--:- __w..,,....__..._..�..=.-.e...__,,.�.-,-...,...„,t..,.,..:��.,,,,..z.,�-,,,,,,,,v,,, ...,,,,,.,,„W,_.�.„,„�,,,.,„-.�..�,Who builds or fmproves-Itie�eon, and--who does sutn-... . � .. .. � . . . _: . , - � � work himseff proyided fnat such imFrovemenfs ere not �. � � ', . , �.__.W, .._.. �:..:- ... ...::, ..._r.,,._-<. ._.,A.�-�-,W....�.�..-..,..-.-:� �.��.,.x,�_p_.�..�,.�-��..:,....z-.. � � --��- �-� , '- �- . . � - i�endedo'rofferedforsdle.l�,`horvauer,itie�bu�(dr`ngor--���� - � '--� � �--� - - � � ��-�- �-.� improvamen�-is sofd with"rn-one yeor of-compfe?icn,ina . _-. -_..,- ___...F-_..___.:.-.--�..-..��.,_�._....,., -��_ � - -.. .. _ . `"�' . .. - """"""�o' n'�bu'17iJer w1Tf have ifie Suiden of proving that ha ditl - -- � - : �� -- ' - - - � � � - no�'bulld or improve for the purpose of soie.) . .-� - :�.: ��:-: . ._�- . ...... ___� . . .� . -..: '� . I am-exemo4 under Sec. ._,_ . __..��.�.� . .:._ ...._. _._-....,�, .__ _._:.___ _ _._:.______.�>..---_._...._-�.._.<,.-�..•-..�.-�>• --- -«w.»G. �.�..,.�.�,..,�-a-....,��, _.-._....::>-.,..0.-�.....;.�-.�..—.� . . . . .. . �,.,�. �„w,...,.:,._...,,,...4_.....e._, ._�,�<.�,� m,., B&P.C.for this reason_ -. � . ... ;.:_ . _. , . . a..�..�.�-.�.«.,� - ..�.:...�_...u.,E.�-..�,_�-..,..,..����.�.s,;..=A...,�...�._t.,_..�-.�„.�� ... . . ...,. . . : ._. .._;.._..,_, ....�.., ..,_-.,,.. .. . .... .._ - - - bate �_:.�,.,....». - . .__ .�._. .. .__'. _._.__._ . _ ....:.... .__._.._._.,__.-. .,:.:�,�-. _,..,__- �>_�..3:,..�.-�.. r - -. . , ._..r-� �..., . .�.�.�-�.-.��,�,��. _,....,...'-:- � . .. _ . � � _ . Owrer .