HomeMy WebLinkAboutNo Permit Number WORKERS'COMPENSATIONDECIARATION 76n663 �oist qpp��CAT10N FOR ELECTRICAL PERMIT {�
I he�eby affirm 1ha1 I hove a certificole of consent lo self �E'�r' .
insure,or a certlficate of Workers'Compensaiion Insurance, COUNTY OF LOS ANGELES D N AND SAFETY ��
or a terlified copy ihereof(Sec.3800,La6.C.J Bldgdl��� A-�1 U
�cy No. 054336 comPo�y wausau FOR A�►UCANT TO Rll IH �oa
Cerfiried�opy is here6y furnished. New Res�deNial Bldgs.8 Pools EACH NO. FEE
ADDRE$$ 2fl721 A-d East Crest Lane
O Certified copy is filed with 1he rounty building inspeo 1 8 2-Family,Sq.Fi. S — 5 IOCAU�Y TR1143718-2
+ro�deparlmenf. Multi.(omily Sq.FI. 4SZU — NEAREST
, Residential 5wimmin Pools CROSS ST.
pa�e 9-28-a7 aPPi;�p,,,Berner Electric, In 9 Owr�Ettoa
� r�aM r,nane Th2 William L on Com an
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Ret_Lighi_Sw._ ���
COMPENSATION INSURANCE First 20 AODeE55 19 Cor orate Plaza
(Tbh s�ctlon nod nof 6•compld.d i{M�work Inrelwd by 7otol No. Add��tionol ��TY New ort Beach CA tel.No. 833-3600
. fh�p�rmH i�for om hundnd dellers(SI00)or I�ss.)
I cer�ify 7hor in the perFormance of Ihe work!or which thit . P�AN CHECK
ermi�is issued,I Shall no�em lo an APPLICANT
p p y y pe�san 7n any mpnne� �� hfin Fixl�res Fiisl 20
so as to become subjecf ro the Workers'Compensotion laws. 9 9 ADDRE55
Total No. Additional
Date aPplicoN CITY Tel.No.
Fixed Appliontes Not Over 1 HP PERMIi
NOTICE TO APPLICANT: If, afier making ihis Cenifico+e of qPPLiCANT Berner �IECtT1C I(1C.
Exemption, you should become subject �o the Workers' Range_Heater_D.W._
Compenwlion ptovisions of the Labor Code,you mus�forlh- Oven _Dryer _W.M._ A�DRESS 75 East Grand 81vd.
with comply with such provisians or �his pa�mit shall be iel.No.
deemed revoked. Hood _Fon _Othe,_ � citY Corona CA 91719 734-3171
LICENSED CONTRACTORS DECLARATION ���N��
Disp. _Room Air Cond. —
I hereby aHirm ihat I om licensed under provisions of Chopter 9 RFG.NUMBER 485322 Class.C�O
(commencing with Section 7000�of Division 3 of fhe Bosiness Power Apporotus 8 torge Applionces DISTRICT NO. PROCESSED BY 6}.�
ond Professions Code,ond my license is In full force and eHetl. �/y
Size 8 iype HP,KW,KVA,pr KVAR � /n �(/'� �
license Number 485322 uc.Gass C10 Up to 1 Ind. FINAI �Y
Contractor Berner EZEC. pa�e 9-28-57 Over 1 to 101nc1. DATE n _I�..q,i' YAtIDATiON �
Ci W
❑ Over 1010 50 Incl. FINAI W
I am exempt unde�Sec. Over 50 l0 100 Inc. BY -�-1 R:
6.8P.C.for this reason
Over 100 ��t'`-, � z
Do�e: Services,Swbd.,MCC B Ponelboards , —
0-2W Amp.Under 600 V
Signatwe 401•1000 Amp.Under 600 4
❑ Over 1000 Amp.or Over 600 V
Exemption for Reg.Moint.Elect.
SINGLE FAMILY Temp.Power Pole 8 Appurtenances �-n�2�7/�
HOME OWNER-BUIIDER DECLARATION Si9n w'dh One Branch Circuil � �2
I here6y olfirm�hot I om exampt(rom the Con�rocbr's License • • � •
Law for the following reason(Section 7031.5,Business and Addi�ional Sign Bronch Circvirs
Pro(essions Code): � • 1 9 1.4 6
❑ I,as owner of the property,will do Ihe work and tha Misc.Condui�s&Condudors
srructure is no� intended or offered for sale(Section Orher(See Comple�e Fee Schedule)_ , ' ° 1 9 1.�4 6�
704E,Business and Professions Code�. ��.�6-&,7
CONSTBUCTION LENDING AGENCY
I hereby offirm ihol lhere is o conslruUion lending agenty for
ihe performance o(1he work for which this permil is issued PERMIi FEE (Sub-To�al)
(Sec.3097,Civ.C.).
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE �O SO �
lender's Address
I cenity thor I hove reod Ihis applicotion and state�hat ihe TOTAL FEE 191 46
above informotion is co.rect I pgree b comply wi�h oll County
ordinances and S�a�e laws requla�ing Electrico�wiring,ond
here6y ouiho�ize representatives of this County io enter upon
fh o ve-menrioned propeny for inspection purposes.
,/j /�� SEE REVERSE FOR EXVLANATORY LANGUAGE
� e n�„^r/'n./r�0/Zr,C/L % ?�'�
�6ignoWre of Perminee Date
�-.�� - -� --•�-� � --- � -� " � -"'-� ''.OWNER-BUILDER DECLARA710N.
�.� � AFPBOVA!S _DATE '�` " - � � .
. _. . _,. ..,. : .- . . , SIGNATURP �. _ . ... .__. . _ . . _ .. _
� - - - � � � � � TEPA?.POIYER 70:E - � � � 1 hareby aifirm thot 1 am exemp+'from 1he Conrroctor's
� ___ , _ . _ � � . � .,Licansa�Law 4or the�following reoson (Section 7031.5.
�-'-�- �- - � ���- UTJD'cR5'A6 WORK�-�� � �,� �,,, '.�' , . ... . . Busfnezs or.d P�o(osslons Codr1:Any d!y or counry whicb
� -- - -- -��- -- - �-- ROJGH CO^1DUT . ��{�Q� . �, � � � - �requlms aparmit fo.consfrutl,a�fer,imprrnc,domolish.
r—[ �-or rcpalr any s�ructurv,prfor to ee fssuanco, aiso re-
-� -- �- � ' � - W1RiMv � - - ' , , � .qvtrnsfhooppBcontforsvchpormltioAlraslgnedsfalo-
� ' " - -� - - menl fhot he islfcenredpursuonf io Ihe provlslons o�Ihe
�� �. ��� FlXTU6E5-���- -� � � ' ,Contractor'a Llcensa Low(Chapier 9(commendng wiih
' � � " � - � _ FO'NEP,AUTHOP.IZ[D .�. ... ' . .. ' ' -- �� � Sccfion 7000J a(Oivlslon 3 0�fhc 9usiness dnd Protes�-
� � � . . sfons CodaJ or fhot he is exempt lhere/rom ond the basis .
UTILITY CO.NOTIFIED �. � /or iho ol;eged axompt7on. Any vlolation ol SacNon �
.__. ._ __ ._. __._ . .
c� _ � 7Q3).5 by eny opplRant 1or a permlt sub(ecfs ther oppli�
' FlNA, . �i�(cr�nn „7ronl - � conf ro o tP�il penafty of not more}han five hundred
_.._._. _. ._ ...___. _ . _ _ .
: � ' � N07E5 � �'� dollors(5500).:
. _. .- ._..__ . . ....__ - ___.... . .. ._� . � ; . . .. - � ❑I,as owner af the a �t �1�do thc�.+ork,and
. , ' , , '� . pr peryw
' � , �ho strucWro is not in!ondod or offered for sola .
._, � . . . . � � . ,� (Soc.7044,Businessa�dAralossionsCodr. TheConerac
__ ' ' - for:Lfcona:Low does not apply to on owner of properfy
' ' - � ' � � viho butlds or�irr.provos fherenn, and who does such
- -� �--�- - - � � �- --"� - - - � ' � work h(msel(p'rov�dod fhof sucfi fmprovemenfs aro nct
_...
' � � - _ � � ' " . � � � - -� � � � "� intended or offored for sofe.Il,howeve�.the boflding or
'��� � �� � � � Improvemonf L^sofd wffhln ono yeor of mmpfef�on,ihe
, �� . , ., � owneo-bu7fdcr'wlflhovelhe6urdenofprov7ngthafhedid
- � ' � nof buifd or Improva for tFe purpos3 0!salo.J
� � (am exempf under Sec. ,
. . ..-� _ � . � _ --� - " . 6&P.C,fcr.this rcoson � .
_ ' . _ . ._. . ., . . . . .-bate �� . .
Owner
, .