HomeMy WebLinkAbout1734A WORKERS'COMPENSATION DECLARATION CEAB06G�O/81 A�PLlCATIOltI FOP. ELECTEtlCA! PERMlT
I hereby affirm ihat I have a certifica�e of consent to self
insure,or a certifimte of Workers'Compensa�ion Insurance, COUNTY OF LOS ANGELES 9UILDING AND SAFETY
or a certified copy fhereof�Sec.38D0,Lah.C.) •
P❑olity�.l( ���Compan�WFST AMFRTCAt�I TNS, FORAPPLIGNTTOflLLIN JO8 1016 COGBURN LANE
Cerfified co is hereb fornished. ADDRE55
PY Y New Residential Bldgs. P Is
n 1&2-Famil s F�. ��� E Q � a 5� 2 �o�^��r�f'R#37034-1 LOT
9,� Cer�ified capy is filed with the county 6uilding inspec- 1'• 4�
tion department MuNi-family Sq.Ft. NEAREST 5. CLEAR CREEK CANYON DR.
CROSS ST.
Residential Swimming Pools OWNER OR
oate Applicant FIRM NAME SOCAIJNID GROUP
CERTIFICATE�OF EXEMPTION�FROM WOKKERS' Outlets:Rec�Light],_Sw.]� .�5 3. 0 q��REss
COMPENSATION INSURANCE F.�g��
(ihis section nead not be completad if fhe work imrolYad by Total No Addi�ianal c�TM oRANGE �92668 Tel.No.580—(j072
1hs permit b for one hundred dollari(SI00)or less.)
PLAN CHKK
I certify ihat in the performance of the work for which ihis APPLICANT
permit is issued,1 shal�not employ any person in any manner
so as to become subject to the Workers'Compensofion.Laws. Li9hting Fiztures First 20 ADDRE55
� Total No. Additionai CITY Tel.No.
Dote Applicant � Fixed Appliances Noi Over 1 HP PERMIT
410E TO APPLICANT: If, after making this Certifimte of ,,Pa,c,,M VIGTOR ELECTRIC, TNC.
,fmption, you should become subject to fhe Workers' Range_Heater_D.W._ K��� ��. �.r� D
Compensation provisions of the La6or Code,you mosl forth- Oven _Dryer _W.M.— ADDRES �
with comply with such provisions or this permit shail be Top —FAU —W.H.— CITY RTVERSTDE 92507 ie�.Nc7.88-9110
deemed revaked. Hood _fan _Other_ �
LICENSED CONTRACTORS DECLARATION LICENSE OR ��a
I hereby affirm that I am licerrsed under provisions of Chapte�9 �'�' —Room Air Cond. — REG.NUMBER 44 10 -
(mmmencing with Sec�ion 7000)of Division 3 of fhe Business - DISTRICT NO. PROCESSE�BY y
and Professions Code,and my license is in full force and effect. Power Apparatus&Large Appliances
d
Size 8 Type HP,KW,KVA,or KVAR ./� V
License Num6er 447105 Lic.Class�^L U 10 7 Ind. FINAL /,/ / O
� - Over 1 to 101nd. ➢Ah � /LI ��y VALIDATION �
!
! Contmctor ELECTRTCA� Date Over 10 to SO Md. fINAI i W
� � I om exempt under Sec. Over 50 to 100 Inc. BY d
B.BP.C.for this reason �e��� y
D Z
Date: Services,Swbd.,MCC&Ponelboards �
0-200 Amp.Under 6�W V
Signature 201-7000 Amp.Under 600 V
❑ Over 1000 Amp.or Over 600 V -
Exempfion tor Reg.Maint.Eletl.
� SINGLE fAMILY Temp.Power Pole 8 Appurtenances
` � HOME OWNER-BUILDER DECLARATION 9 z 1 7 a 4 A
Si n with One Branch Circuit
i �'eby affirm that i am exempt from the Coniroc�oi s License qdditional Sign Branch Circuits �
I i�w for the following reason(Secrion 7031.5, 8usinass and �� • ♦ . •2
� Professions Code):
I,as owner of Ihe property,will do the work and�he M:sc.Condai�s 8 Conduciors � � �7�2 2
I ❑ structure is noi intended or offered for sale(Section Other(See Complete Fee Schedule�_ �
7044,Business and Professions Code�. • • •7 2 G 2�
CONSTRUCTION LENDING AGENCY O Z 2 7—H Q
I hereby affirm thot there is a conshuction lending ogency for
the performante of ihe work for which this permit is iasued PERMIT FEE (Sub-Total) 61 �2
�Sec.3097,Civ.C.). - . -
PLAN CHECKING FEE
ILe�er's Name 1 O`$Q
! PERMIT ISSUING FEE
Lender's Address
I certify�hat I have,ead ihis opplication and sta�e�hot�he TOTAL fEE ]2�2Q
above informa�ion� correct.I aqree to compiy with nii County .
ordinances and �awsf ulafing fledriwl wiring,and
herc!�y aothor'.e repr 9at ves flf.lhis County to anter upon
tHe qbwe-mentio+�c ope yPo�m3 ction purpo s. - SEE REVERSE FOR EXPLANATORY LANGUAGE
t ..--''� � ���{.r�
��' :
r ��gLnture of Per�ttee � Date
�
I
I z '-' � $ = �. o Z �
I o y =� � � ,� � o �
i N r n D vmi 'n � � � �
O � � �
� 2 Z ay O
� � � C A v rD-
� T m � � m N
rn �
v
I �
i
i �
� v
� � �
a
�
�
. �
� �
c
�
m
i
i .
� �
I .
p � — � o ' � F f o'in T p$ o o" m o 3 c � � c n �-
O � Q� � O j T! �C � O q fsl y� -'i �, 7 .�i.7 �1 '7 C N � m
. � � ,� o C � � ��.C n'`r n ❑t� p �q A 7 n S�O N N m�
n p ae 3 a3` • � �c-�c� o �oo °o 'o c n
0 3 ° aY ° m N o mw' w g^ � m'o o"�et° �n '�-F � 0
v m ��o o w v F�-:.'�m ' o ,�-, �a w 3 �o'3 �
S c vf.� Wo .fov3 �-°oa="''� no � �o Z
. N 7 O �p � t 3 Q n m �� W Q �� 0 4 � u T� .'G
W �a � �-a�yao ,� � � Q x �-< ou ^ ° No _ o0
a ° o • a � � � —a� m �; �� �; a � oa =
N �„ o� f � am � �y.� s < �� � o c c-a W ,�. N r-
� � S�-o T`" °, ym° °.c- `� ' F a nv � n�3 � .
�m � ,m'O. �-o c Q--° � ' � � "�� ?'-. �°yf. X �
o s o �
' cc ' "c 'aba �n �vD? �v° � o ' e:°�o � m
� �� o�-�� o �,� o °�'c 3-�� 3 � m DO� n
� o � m ° � ° � 3 m � o ❑ . �°� o �, D
� p`� C� p � O�p' .f 0 a O m �•o S�u' . � o O A
�
N a °•W < a� �s o a o a-o o _'m ov �c�oi.,3 -Di
° `- 0..�'-3 .frm u 3 a o`'' 3 N 3 0 o a o � m � O
!�,n 3 �o W o � -�° � <w ' � n m 4 � ^ '-�° a �• n
`�.v�c'N a°,m° � o So,y'a� o� 9 Q> > >
y -� _' �ry�O (1 O 7 0 N S � p p,�iD V'
�-� a° '" ° � ?r � o � iD 'D°p �� N o� o 0
,.-. �u - � '� u� � .�. aa :..4° � oo N � �=o'
a�° ° T� ^ - a�� � � � i-�� w �-3."''w'