HomeMy WebLinkAboutNo Permit Number (61) ��. WORKERS'C061PENSATIONOECLARATION 76A683 �oie� qppLICATION FOR ELECTRICAL PERMIT � {�'.
I hereby affrm tha[I have a certiticate oF conseN to sell insure, CE-8o6G .
or a certiticate o1 Nkrkers'Compensxtion Insurance,or a certified U OF LOS E S � BUILDING AND SAFETY �j
co t o ($eq�00,Lab.QI _
Poli j, COmp3ny FOR AF7UCANT TO Flu IN JOB
❑ Certitied copy is hereby fumished. New Residential Bidgs.8 Pools EACH O. FEE AODaESS m
t�^ Certified copy is liled wilh Ihe eounty building inspxtion 1 8 2-Family,Sq.Ft. S = S LOCALITY
de�r ���Yr{ �n . Muiti-family Sq.Ft. ..3 7 7 NEAREST
��rl�' " +�'�"� ReSidenlial Swimmin Poois cnOSs sr.
Dat App!icar.t X�.1�X+ 9 OWNER OR
FlRM NAME
, CERTIFICATE OF EXEAIPTION FROM WORKERS' . � � � MAIL
Outletr Rec LigM Sw.
COMPENSATION iNSURANCE � s, AO�fiE55
(This sedion need not be completed It the work Involred by tbe r-� � First 20 CIT Tel.N,
� permit Is for one hundred doliars(5100)or lesa) � Totai No.� Additional
I Certif that in the performance of the v�prk(or whiCh thiS Permit PLAN CHECK
Y APPUCJ+NT
is issued.I shall not empioy 2rry pErson in arry manner So as to �
-- become subject to the Workers'Compensation L:ws. L'ghting Fixtures First 20 ' S w ADDRESS
. Total No.�_ Additional CITV . Tel.No.
Date Applfcant Fixed Appliances Not Over 7 HP
NOTICE TO APPLICANT: If, alter making this Certificate o1 PEHnnir
Ezemption,you shoultl become subject to the Workers'Compensation Range_ Heater_ D.W. _ A[��iCnM
provisions of the Labor Code,}rou mu5t`orthwith comply with such Oven_���ryer_ W.M._ � ADDRESS
provi5lons or this permit sha�l�e deemetl rewked. Top _ FAU _ W.H._ �� Tel,N
LICENSEO CONTRACTORS DECLARATION Hood_ Fan _ Other_
I here6y aftirm ihyt I am licen5ed un�ler provisions o1 Ch�pter 9 uGE SE OP.. )
(COmmfnGng With SeCtiOn 7000)Of�iViS�On 3 Of the @u5inC55 end DiSp. � F1ooR1 Ai1 C,Otld. _ l7EG.NUMBER Class �
ProfBSSions Code,and my IiCenSC 15 in full fOrce and e�(ect DISTRICT NO. ' PROCESSED 6Y
Prnver Apparatus 8 Large Appliances
, 1Qr�� � Size 8 Type HP,KW,KVA,or KVAR � � v O
License Numb1e�r�t'OCII�-t� Lic.Class +5.�1� . � Up�0 1 Incl. FINAL .f . - V
�I1...►n Over 1 to 10 Incl. OATE � VALIDATION �
❑Confractor�Y1J.Y. Dale� Over 10 to 501nc1. . . _ ^ i . . . , V i
FINAL
I am exempt under Sec. Over 50 to 100 Inc. gy �y5% �
B&P.C.for this reason Over 100 �•y
N
- Services,Sw6d.,MCC 8 Panelboards � .. . � ., �
Date: D-200 Amp.UnCer 6D0 V
Signature � 207-1000 Amp.Untler 600 V ,
❑ . . . Over 1000 Amp.Or Over 600 V
Exemption tor Reg.Ma�nt Elect.
� � SINGLE FAMILV Temp.Po�r Po!e&Appurtenances `1 ���7 1�
� HOA4[OPJNER•BUILDER DECLARATION Sign with One Branch Circuit � � -- � --- - ���. o , . n j �
1 hereby�Ifirm that I am exempt Irom the CoMractor's License Law ptl^dional Sign Branch Circuits
for the followirg reason(Section 7031.5,Business and Prolessions
coae�: 1 •2 4 5 7 G
� Misc.Conduits 8 Conducrors _ . s
I,as owner of the property,will Oo the wo�k and the structure Other�See Comptete Fee Schedule)_ �C G��7��,
is not inteMed or oHcred for sale(Seclion 7044,Business ,
and Protessbns Codel. 0 9 0 8—E F3
CONSTRUCTION LENDING AGENCY .._ ... _ . . . . . . .
I hereby affirm ihat Ihere is a construttion lerding agenCy for ihe
pertormance of the urork for which this permit is issued(Sec.3097, pERMR FEE . .. , ISub-Total) � 7 _ _ _
Civ.C.).
PLAN CHECKING FEE -
LeM=r's Namc � � � �
PERMfT ISSUING FEE .
leMer's Address � � � �� � � - - � � �
I cert�fy that I have read this 2pplication and stato that the above TOTAL FEE � f�.
informatan is coimct.I agree to comply with all County ordinances' � � �' � �
antl State laws re9ulating EI>ctrical wiring,and here6y authorize
representa!ives of Ihis County[o enter upon�he above-mentioned� �� � �� � - - -- - ��� � � � � �� � .
property lor insfl�iti purpases.
� ;� SEE REVERSE FOR EXPLANATORY LANGUAGE
�.l Q
ignatwe ot Permitlee Date � ,
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