HomeMy WebLinkAboutNo Permit Number ' WORKERS'COMPENSATION DECLARATION ���3 �a�$1 APPLICATION FOR ELECTRICAL PERMIT
I hereby af(irm that I have a cerlificote of consenl to self CE-B06G
inswe,or a cen�fico+e of Workers'Compensotion Insurance, �OUNTY OF LOS ANGELES u D N AND SAFETY
or o cerii(ied copy thereof(Sec.3800,lob.C.) Bld #�3D�' A-�
O�y No.054336 compa�y Wausau FOR A►PIICANT TO iLLl IN �09
CerfifiefJ copy is hereby furnished. New Residentiol Bldgs.8 Pools EACH NO. FEE ADDRESS 2�]3� {�—� E. Crest Lane
� Certif�ed copy is filed w��h the couniy building inspec- �g 2-Fomily,Sq.FL S — f LOCAUTY TR4i43718-2
r�on department. Mulr-fomily sq.Ft. 4524 — Neae¢sr
9-2$—$7 Berner Electric, In . Residenfiol5wimming Pools � CrtOsssi.
Date Applicant OWNER OR
FIRM NAME The William L �(1 C�m an
CERTIFICATE OF ExEMPTION FROM WORKERS' Outlels:Rec_light_Sw._ '�'��� �
COMPENSATION INSURANCE noorte55 19 Cor orate Plaza
This s�cfion n��d nof M com I.�.d i}�h•work tovoir.d b First 2(1
� P Y Torol No. Additfonal cirv New ort Beach CA T��.Na. g33-3600
th�p�rmtt fs/or on�hundnd dollar�(SI00)or I�a�.]
I certify ihat in fhe performance of the work for whitM rhis . qppij�NTK
pe�mit is issuad,I shall noi employ ony person in any manner
so ns to bacome subject to�he Workari Compensotion Lows. ��ghiing Fi.�ures Firsl 20 ADDRESS
� Total No. Addiiiona�
Date epplicant CITY Tel.No.
NOTICE TO APPIICANT: If, after moking fhis Cerlifitate of Fized Appliantes No�Over 1 HP PERMI7
� Exemp�ion, you should become sobjac� ta the Workeri Range_Heater_D.W._ nPPtiCnNiB rf1QS EIECtr1C 1(1C.
Compenso�ion provis�ons of�Me Labor Code,you must for�h- Oven _Dryer _W.M._ ADDRESS 75 East Grand 81vd.
with comply wilh s�ch provisions or this permil Sholl be Top _FAU —W.H:—
deemed�evokad. Hood _Fon _Otha�_ CITY COTOf18 CA 91719 rei.No.734-3171
UCENSED CONTRACTORS DECIARATION L�CENSE OR
�here6y offvm thot I om licensed onder provis(ons of Chopter 9 Disp. ,..—Room Air Cond. — REG.NUMBER 485322 Ciass.C��
(commencing with Sect�on 7000)of Divis�on 3 of the Business DISTRICT NO. PROCESSED 6Y
and Profess�ons Code,ond my lirense is in fu0 force and eHett. Power Apparotus 8 Large Appliances � �1 wJ O
Size 8 Type HP,KW,KVA,or KVAR ()
license Number 485322 i;�.e�os, C10 Up fo 1 Ind. FINAL
DATE �I� �^.,o a
Coniractor 8erner t1EC. Do�e 9-28-87 Over I to 101nc1. lJb YALiDAT10N �
❑ Over 10 to 50 IncL FINAI W
I am exemp�under Sec. Over 50 ta 100 Inc. BY p_�
6.87.C.for Ihis reason Over 100 N
Services,Swbd.,MCC&Panelboards , Z
Date: 0•200 Amp.Under 600 V '
Signatu.e 201-1000 Amp.Under 600 V
OOver 1000 AmP.or Over 60p V
Examplion for Reg.Main�_Elec�.
SINGLE FAMILY Temp.Power Pole&Appunenonces
� HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm thai I om exempt from ihe CoNroctor's license Addilional Si n Branch Circoils -
Law for the following reason(Section 703L5,Business and 9 �� 2�0�{
Professions Code):
❑ I,as owner of the properly,will do ihe work ond the M;sc.Conduits 8 Conducfors �• • • • �2
shotrure is nof imended or offered for sale(Section Other(See Compleie Fee Schedule)_ , �� � � 1 9 1,4 6
704A,B�siness and Professions Code�. '
CONSTRUCTION IENDING AGENCY � � • • 1 9 t t�b�
I here6y nffirm that there is o construction lend�ng agenty for _ I D,t 6_8,7
the per(ormance ot the work for which�his permii is issued PERMIT FEE (Sub-Total)
(Sec.3097.Civ.C.).
PLAN CHECKING FEE
Lender's Nome
- PERMIT ISSUING FEE - � �O SO �
Lender's Address
I tertify ihot I hove read this application and state Iho�the TOTAI FEE
obave informotion is mrrect.I agree to comply with oll County
ordinences and S�afe laws regulating Electricol wiring,and
hereby authorize reprasentotives of this CouMy 7o enter upon
the a6ove-menrioned property lor inspeuion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
���lj,r„�_!��—,,�,�ti , � ���� .
�Signature of Permiliee Dole
... - .. . . ..•...-� - � �� � ,;,,. � -:;- --� . ..----.' ...- -"�- . .R-BUILDER DECLARATION
� _.. ,/+p?ROVALS � _.. . �ATE , i OVJN° .. � .�
- SIGNATUFF- -- ��- - - � '�- � � -� -� �
�--�� -���- � � � 7E1.'�P.FOWER POLE, , � - � --�� � � ' . ' '" '�: 1 heroby pffirm tfia'I am exemp�from thc Conlrac�o.'s�
� _ _ _ � . . . , .licenso,Law for.lho following reasod (Secfion 703I.5,
�-""- �' �'�-"`-'"--- UND[^SLAE INORK . � � � . � • ' � Puslness and Prolesslons Code)�Any cl�y or covniy whlth
- P,OUGN CON�UtT - . � � I -. � � �reqWres c permif�o mnsfruc6 of+er,improve,demolish,�
i � � � � � ':� �-� -or�repv��-cny"sfruNure,prtor fo Hs Issuance, cho re.
. � -- � -- ---�--- � VlIRING ' � - � , , , qvfrosfhoappUcnntforauchpermllfofileazlgned:tafe-
- ' ..:. FtX.7URE5 ' . � � - � ment thef he fs Uccnsed pursuartt fo fhe provis(ons of!he
--- --""� "�- '�� ' " ' �Confroclor�ticense l�w(Cfiapter 9(commercing wllb
, '� � � � ' ' �����^FOWEr'.R'JTE{ORIZED . �. -- -�. . ..__ • ��� � - - '� � '� � Secfion 7000)o/OJvlslon 3 0l the Buslness end Proles-
. � � slans Codo)or ihof ho Is exempt Iherefrom ond Ibe basis'
_ UTILITY CO.NOTIFIEO " ,. -ior fho allaged exempflon Any vlolotlon of Secfion
, F1NA: _ ' Gnfcr nn _jrodf -���__ � � - � ,JC31.5 6y ony appRcont for a permlt subjacts ehe appl�-
- - �-- �--- � - , ., , cant to o dv11 ponalfy of not mo�e lhon 1lvo hundred
� - � � NOTES - � . ��- - - doilors(5500).� , � . .
._.. _.__.. .._.. _.__. . _ . . . __ . ' . - __. ._ . _. . _ .
, , � � � ' �;�1,aa ownor of iho propurty wiU do�he work,and
� � - � the strocmro Is not ir.tcnded or offared tor aale.
� .� -. . _ -- _ . _ .... , . {Ssc 70Ed,Quslnese ondPro(esslons Cade: Tbe Confrac
� � ' - - - tor's tican�o Low dcos not apply lo an ownerof propeny
' ' �� ��� - � . � .. . . , . 'who 6WIds or�lmprovos iheruon, and w6o docs such
� , � , � . - -'- -"-- �- work himsel!provldnd Ihh!sucb Jmprovoments are no�
' '��-• � � � - � �- - '' � � ; �. � lnlended or offerod for sa/e.�N,howeveq the 6u1lding or
'� �� � �� � � � "-� -� � � � � ImptoJemeni Is sold wtihM one year p(complefion,fhe
� . � , ' . ' , � � ownor6u�fdcr w(I!have Ihe bvrdon of provMg fhat he did
. � � ' � ' nof bWld or Improve Jor the p�rpose oi sale.)
,. ., --- ._.. ._ .� . . . .. _ . �
� ' - � � ' I am exempt under Soc.
; .� _.. . .._. .. � �.- ._ --- � .
_..8.8 P.C_for this reoson
� _ . . _ • ' .
. . . � ... . __..�ote
� � ' Owner ' .. ' . .
-- -- -� - ' ' ' � � ' � , , . �, � „ ,.
. �.. .. � � . _.... ._, . . .. , . , , - � .,
� . � .. � � ,. . . . . . . � , . . . . . , .