HomeMy WebLinkAboutNo Permit Number (5) WORKERS'COMPENSATION DECIARATION 76A6� ,0.8, qpp��CATION FOR ELECTRICAL PERMIT �
1 hereby affirm fhat I havc a cerlifico�e of consent to self Ce-e06G
inwre,or a cerrKcme of Workers'Cor.�pensatioo Insura�ce, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a ceriified copy Ihereof(Set.3800,Lab.C.) Bld 4135 8-1
aCy No 054336 �ompo„Y Wausau FON AP/UCANT TO Flll IN .108 .
Cerii(ied copy is here6y furnished. New Residential 01dgs.&Pools FACH NO. FEE /+DDRESS 20702A-D E. Crest Lane
� ' I 8 2-Famil LOCAUTY
Certified copy is filed with the county building inspet- Y�59�Ft. s — S 437�8-2
tion department. Muhi-family Sq.Ft. �1524 4 — 1$0 96 NEnke57
ResidentiolSwimmin Pools �RO555T.
p�g`z$—a7 qPP���a��B2TflEI' EZECtT1C� II�I . g OWNEROR
� � fIRMNAME The William L on Com an
CERTIFICATE OF EXEMPT�ON FROM WORKERS' Ovtleis:Rec_Light_Sw._ ���
� COMPENSATION WSURANCE Firif40 ADDRESS �J COT orate Plaza
{Th{s a�efion nwd not 6�cempl�f�d�f fh�work tnvelv�d by Total No. Additionol CITY NeW ort Beach,CA Tel.Na.$3'J—'-�600
th�p�rmit i�for oae hundr�d dotian(S100j or I�a.)
I certify that in the performance of the work tor which this q pNCqNiK
�permil is issued,I shall not empioy any person in ony monner .
so as fo hemme subjecl to the Workers'Compensotion lows. Lighting Fixtuies Firs�20 ADDRESS �
Tolal No. �+dditional
CITY Tal.No.
Date epplicaN Fized Appliances Nol Over t HP PERMIT
NOTIGE TO APPUCANi: If, afrer making Ihis Ce�trficate o( APttICAN rn EI tT1C If1C.
Exemp�ion, you should 6ecome subject to the Workers' Ra�9e_Heater_D.W._
Compensotion pro�isions of fha La6or Code,you musl forth- Oven �Dryer _W.M.._ ADDRES$ 75 East Grand Blvd.
with comply wilh suth provisions or this parmil shall be 7op —FAU —W.H.—
�deemed tevoked. CITY C rl A 91719 Tal.r�io.]34-3171
LICENSED CONTRAC70R5 DECIARATION Hood _Fan _Other_
Disp. _Room Air Cond. — kEGN ur�.+Reee� 485322 Clasa. C10
I heraby pffirm�hat I am licensed under provisions of Chapter 9 �.:
(commencing with Section 7000)of Division 3 of ihe Business DISTRICE NO. PROCESSED BY 4'
and Professions Code,and my licanse is in fuil force and effect. PO�^'er Apparatus 8 Lorge Appiiances � �
Size 8 Type HP,KW,KVA,or KVAR
License Number 4HJr3`LZ Lia Class C�� Up to 1 Ind. FINAL �
Berner Elec. 9-28-87 ove�1 lo l0 1ncl. DATE Z��t,
Conrracior Da�e F1NAL F_:,u VAUDl1TIOH W
Over 1010 50 Incl.
❑ I am exemp�under Sec. Over 50 to 100 Inc. BY ��r 0-
�
B.BP.C.fo�Ihis reason Over 100 � Z
Oaie: Services,Swbd.,MCC&Paneiboards . � ,
0-400 Amp.Under 600 V
Signature 201-1000 Amp.Under 600 V
❑ Over 1000 Amp.or Over 60p V `
Ezempfion for Reg.Moin�.Elect. � '2�(j A
SINGLE FAMILY Temp.Power Pole 8 Appurtenances �
HOME OWNER-BUILDER DECLARATION Sign wi�h One Branch Cirt�il u� •• � •2
1 hereby affirm that I am eaempt from the Convador's License Additionol Sign Bronch Cirtuits � � • � �'���l�]
Law for the following reason(Sec�ion 7031.5,Business and
� Professions CodeJ: � z
� M:sc.Conduirs 8 Conduc�ors • ] 9 1.4 6 c�
I,os owner of the propery,will do the work and the
structure is not intended or offered for sale (Seclion Orher(See Complete Fae Schedule)_ , � I Q,�b—H 7
7044,6usiness and Proiessions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm thot there is a construcfion lending agency for
the pertormance of the work for which this permit iz issued PERMIT FEE - (Sub-Totai)
(Sec.3097,Civ.C.). .
PIAN CHECKING FEE '
Lender's Nome
� PERMIT ISSUING FEE �O S
Lender's Address
I certify that I have read this applicotion and state Ihat the TOTAL FEE �
above informotion is correcl.I ogree to comply with all Caunly
ordinances and Staie laws reguloting Elecfrical wiring,and � . �
hereby authorize represen7atives af this County to enter upon
the above•mentioned property for inspeciian purposes. SEE REYERSE FOR EXPLANATORY LANGUAGE
ti�c�: n t�/�'-- �1-7.-�9�£�7
ignat�re of Permifree Date
. , .__. .. ...._.. �� AFPROVACS . DATE � . . .. . . . . _ .. _. .. _. . . . IL�EP. .C. _ .
'ON'NER-BU UE LARATION
� ' -SIGNATURE � . .... . � . " � .
���' TEMP.FO'rVER PO.E �- - � - � " � ' . �� I haroby affirm'ihat I am exempi from.the Contro[ior's
.. � , � . , licenso Low £or fhe following reasan (Sec�ion 7031:5.
. ._.__... _._ . .. _--- UNDERS!ABWORK � . .- . :. . - � �.���. , _. � . BusinessacdProlosstonsCode)�Anycltyorcounr�wb7cb
- � -� ROUGH CO"I�UIT �� ��- ' � - . � .: � . -roqWraa v perm7l ta consfrucl,aNer,improve.demolish.
_.. _.-... . _.___ . �_�_ . . --�-'ar rvpalr any slrucfurc,pNor�fo I�s itsuanco, olso re-
�.�;�. -� ���..-;, �. �� . . WIRIM1IG-- .^ - : � qufres Iho opppraal forsuCh permff fo 1Uc,o slgned rtvfo-
. _. _ . . �. FlXTL'nF5 � � � ,� -� �� . � manf thaf hc Is ifcensed pursuartl ro fheprovlslons o�f6e
� _ - - , � , .Conrracto�i Ucense-Law{Chaptar 9 jcammenNng w/�h
_ � _ � _. ... _ ..;�FO'.VERlILJiNORIZL�� . . . _ . . " -- - � ' �Secfiort 7000f of.Div/sion]o)the-Bvsfness ond Prolgs-
� � � , � �� slons Codo)or lho+hc is e+empt Iherelrom cnd fbe basis
. _ _ UTl'ITY CO.NDTiFIED � ! !or fhe�.allepad-uxomp�ion..Any NoloNon o( SeUbn
rc7 . 7031,5 by any oppllconl for o pe�mff subjects tha applh
. � FlNAL C+i(cr o.e yronL � � � �• conl to a clvi!penolfy o/not more thon f1vo,hundred
.____. .. ..'_ - __ .
� . .. ' NOTES . .- - � doflars(3500).: ,
�. ... _...._ .. �_�_ _ . . ----- - - � , . .. . . . . . .
. . �� -� � ' . -��1,as owner of iho property�will do�he work,and
� �� - - � �� . the stmcturo is not inlended or offered far sole:
, . . �� � . � . � . ,(Sot.�70GC,Bus/nvssandPratosslonsCodr, iheConfroo
� _ ' � �Jor'S Lltanac Caw does noi appfy�fo an awnrr ol properly -
. , . � � � who bWlds ar'Improvos fherenn, ond who does soch
, .. : ..,. . . .... - .. ..
� �� ' � " ' � - "� work Fimeolf providad fhol such fmprovemenis oro nc�
. . ._ .____ . _ . .
� t I-.� ��� • `� �� -� � - -- �- - � ��' � � � - - Intended ar n/fered for sofe,If,howvver,�fAe bufld�ng or
. � . "... .. `...._.".. �.�.-.- .�._ ... .. . . . ..� lmprovamonl 1;sold w;�htn one yeor ol rompleilon.fhe
' _ � ��, �. � . . � owner•bvllder w1U heve!he 6u�d�n ef proving lhot hc did
� ' � �� - � ' ' � � no1 bvfld or lmpro✓a(or tFe purposs o/solo.) . ,
. . , � � � _. _ -. . ... . .... .. . . . .
� � - � _ I om exempi�nder Soc. ,
�. ._.�.. - � . . . .. .� ...� � � . . _. 6&P.C..fcr this reason . � .
. � ' � . . �. __..Cate -- _. .._ � � .
'��.1`.„ , , . �, Owner � . . � . , � �.