HomeMy WebLinkAboutNo Permit Number (5) WORKERS'COMPENSATIONDECLARATION ���3 �o,B, ppp��CATiON FOR ELECTRICAL PERMIT
I hereby afFirm ihat I have a certificate of wnsem�o self CE-B06G � �
insure,o�a cerrFlcote of Workeri Compensation Insuronce, COUNTY OF LOS ANGELES BU LDING AND SAFETY
or a certilied copy thereof(Sec.3800,Lab.C.) Bld �t34� A-2
�cy No. 054336 Company wausau fOR A%IICANT i0 FIIL IN �oe
Cerrified copy is he�eby furn�shed � New Residentfol Bldqs.B Pools EnCH NO. FEE ADDRE55 20711 A-D E. Crest lane
� Certified copy is filed with the munry building inspec- 1 8 2-Family,Sq.FI. E — E LOCALITY TR#43718-2
rian deporfinent. Mulli-family Sq.FI. 4524 — NEAREST
Residential Swimming Pools CROSS Si. �
Date 9-28-87 ApplicanB - f1P_T �PC rir. Ifl . OwNEROR
F�RM n,,arne The William L on Com an �
CERTIFICATE OF EXEMPTION FROM WORKERS' pullets:Rec_Light_Sw._ ��� P
� COMPENSATION INSURANCE First 20 ADDRE55
. (Thi���ction n��d nof b�cempl�t�d 11 th�werk Iwvolwd b� Totol No. Additionol �'TYNew ort Beaeh CR Tei.Na.833-3600
th�p�rmN�s for en�F�ndr�d dollon(S100)or I�ss.)
I cerlify that in the performonce of ihe work for which this AppN�qNT�
permit is issued,I sholl nm employ ony person in any manner .
so as to betome subjed to the Worken'Compensa�ion Laws. Li9hnng Fixtures Firs1 20 ADDRESS
Totol No. Additional
Dale °PPlicont CITY Tel.No.
NOTICE TO APPLICANT: 11, after moking this Certiticote of Fixed Appilonces No�Over I HP PERMiT
Exemption, you shoold become subjeU ro �he Workers Ronge_Heater_D.W._ . APPUCANi Berner Electric, INC.
Compensot�on provisions of the labor Code,you mus�forth- Oven _Dryer _W.M._ ADDRESS 75 East Grand Blvd.
with comply wiih suth provisions or this parmi� shall be Tap _FAU —W.H.—
�deemed revoked. Hood _,Fan _O�her_ ��7Y COT0f18� CA 9�7�9 Te1.No.7jQ—j�71
LICENSED CONTRACTORS DECLARATION I�CENSE OR
I,hereby affirm fhot I om licensed undar provisions of Chapter 9 Disp. _Room Air Cond. — REG.NUMBER 485322 . eiou. C 10
(commencing with Secfion 7pW)of Division 3 of Ihe Bvsiness power ApporoWs&lorge Appliances DISTRICT NO. PROCESSEO 6Y Q:
ond Protessions Code,ond my license is in full force and affect. O
485322 Size 8 Type HP,KW,KVA,or KVAR 2 � t,4f1 U
litense Nomber lic.Closs C�� ' Up to 1 Ind. �
FINAL
Contmtlo�erner Elec. pp1e 9—ZS—B7 � Over 1 l0 10 Incl. DATE �� � yqUDAT10N V
❑ Over 10 ro SO Incl. FINAL W
I am exemp�under Sec. Over 5010 100 Inc. BY �� �
B.BP.C.far fhis reason �Ve��� Z
Da�e: Services,Swbd.,MCC 8 Panelboards '
� 0-200 Amp.Under 600 V
$ignoture 201-1000 Amp.Under 600 V
OOver 1000 Amp.or Over 600 V
Exemprion for Reg.Ma�m.EIeU. �1 2 5 5 A .
SINGLE FAMIIY Temp.Power Pole R Appurrenances
HOME OWNER-BUILDER DECLARATION �• • • • •2
Sign with One Branch Circuit
I hereby affirm iho�I om exempt from�he Contractor's License qddifionol Sign&onth Circuifs •
low for the following reason(Section 7031.5,8usiness ond I 1 9 1,4 6
Professions Code): �
� M;sc.Conduiis 8 ConduUors • ' 1 9 1.4 6 c=.�
I,as owner of the propeny,will do ihe work and rho
siruciure is not intended or offered for saie (Section O�her(5ee Comple�e fee Sthedule�_ , � Q� 6_$7
7044,Business and Proiessions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
the performance of Ihe work for which Ihis permii is issued pERM1T FEE (Sub-Tolal)
(Sec.3097.Civ.C.). �
PLAN CHECKING FEE
Lender's Nome
PERMIT ISSU�NG FEE � S
Lender's Address
I cernly�hat I hove mad ihis applicaiion and s�ate ihai the iOTAL FEE . � 4
above information is correc�.I agree to comply w�th all County .
ordinonces ond$tafe laws regaloting EleUricol wiring,ond
hereby outhorize representatives of this Coun�y to enter upon
the a�b/ove-mentioned property tor inspec�ion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
��[�QZvrfYn�6'.LP�r_Itlr-`f/ �7�"C� .
�6ignoture of PermiBee � Oole
........ . . ....._ __.._. � . . ` �� - ,,r« �.o . _ ._ - ._ .. .... . - . i�OWNER-6UILDER OECLARATION .
� AFrRO'✓A!5 DATE SIGNATURE - . -.- .. ._. .. -.- - . � ..
��" ---- "" -"--� � '- "- 7 � � � � � �� '� I hereby a(firm thct I am exempt from Ihe Gontrotfor's
� Eh',P.POV/ER FOIE - �-��
___, `- � � ' � � li<onsa�.Law forlhe following reason (Sec7ton 703L5.
._. ... __ . .� r . . �
� ��--- " " -��"-" UNDERS!f,3 YJORK � ' - �-� � �: �• Business ar.d Frolossions CodaJ:Any cify or counfy whlch
._..____ _.. .. . _ ..__.__.
- RO�GH CONDUIT' ��� �,(LQ� . �N .. .' � �. � � '� . � � . requlros a pormii lo conslruct,oNer,lmprove,.demolish,
. . ,.. - .. ' .— ...:.. . :-or-ropoir any strudure, prlor fo--7fs lssuanco.�olso re. .
���--- '-- �-� '��� ''=--"- ��� VdIRIN6 �' - q�tros f!�p trpplicanl lorauch permlt lo llle v s�gned stafo-
-_ - � . �. FIXTUR:S- �- �- menf lhat hc ls 1lceotedpurs�onf lo fhc provlslons o1 fhu --
' --� �� � ' Controctor's llcense Lew(Chopfer 9(commencing w/fh
� _ . � ' �� � � �' � PO'NER AUTHORIZED�.��.: .. �._. -. �' -� � ' �' -Secfion 7000)ol Divblon 3 0!tho Business end Proies-.
� �� sfons CodeJ or fhot he tz exe:np!lhere(rom ond IF.e basis �
; _ UTI!ITY.CO.NOJIFlED ' �� . -:/or�fho cl;agad oxomplton.�Any.vlofafion of Secllon
�.� . . . .. ..� FMA: ' �'� . .. � . ... ' ' � �� ' : 7C31.5 6y any a�phcan}for a permll svbjects fha oppU. .
.._ . , _. . ._ ._ nler oa iorsf �onr to'a c�v/f penalty ol not more tAan/ive hundred
! � '�� NOTES ' � � �- �- �� dof fors(5500).: �
.. .. . --. .. . ..... . . .. . . . � . . � . . ..❑I,�s owncr of tho praperty wiC do Ihc work,and
� � ...1ho stcuclure is not intended or offorod for sale. �
. � . . . , . � .. ,. . � . �__ � ($ec.704S,EuslncssondPrototslonsCodr, �TheCon}roo-
- � � ' - � � �.��or's Llconae Low does no�apply to on owner of properfy
.. __... . . . ._ ,
, � � -� � .. , � . , . who butlds or'improvos fheroon, ond who does such
-- �� ��- "� �-���--- --- " �- � - � � � work h7mse(f proNdad fhot socfi lmprovemenls ore nef
��` ' � � - >� '� ' � � � � � -- � �� � - - - Jr.tended or olfored!or sale.If,however,tha 6Wfding or
�.. .. ..... ... . ........� . . . . ... ... . . . imprv vemonf L•soldV+ll6in onc yeor of comple!lon,fbe
� , - ' � , : � owner-bW/derw(Ilhavcfhobu�denefprovinglhathedid
�. � � � - . noi 6ulld or Improvo!o�fhe�purpose of sole.)
..: ._. _ ... � . .. . _. . . - . ... . _ _ .
� I,am exempt vnder Soc.
. . . .. � . .. . . .B 8 P.C,fcr this rcosan _.
._ .. __. _ . , . . ._ Date � . .
ii��. _ � . Owner . . . .. � �
... . , i - ._ . ... . � . � .. .. . . .