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HomeMy WebLinkAbout0982A WO(tKERS'COAIPENSATIOTv DECLARATION - 76A663 /�n��� �.. . �.� ��� . ....` , .' - � u �.. . . .. . �E-�80 G(2S0)� fir �,�,Q,.I�.�..,��t.�L.�....��.�,1C.Q►L PERMIT._ . �.. I hereby a�fuAL_that 7.ha4e a certifi�ate of:canserct�yo�s�tt ,,._�{`,,Q,U7,V,TX;Q�L¢$�WS'iELES. BUII,DI[NG`ANDSAFETY .insure Q[a..cezttflc.ate of WorScers-Compensation Insurance or � - ' � '` ` -aceri�&edcopy.theceof Sec.38Q0,-Lab.C�J�/�' ' -- '" ` " -: . �� - `�' . -" � �::� � " � - - ' �s— FpRAPPLICAIVTTOFILLIN �pg i��l���Z � Policy N Company��"� �(� New Residen[ial Bldgs.&Pools EACH NO. FEE AODRESS p,� �$ ������q� � _____.._ :. _❑ Certified cop}•is herebY furnished. � � 1&2-Family,Sq._Ft: - S � —�$ LOCAUTY f '-.�.... - --. � �Certifiedcopyi6.$ledwith;he.county.buildingirtspection Multi-familySq.-Ft, CROSSST depar�`t�,m��en�'L// �_�/1 Residentiai SwPmming Pools� � - . OVYNER OR � �. /y_. � `r_/ � Datej�/�7�APPI ceilt'�`!�'^�i6�i=�-�i6'�f. .. .. . . F��iM NAME . C/ _ . OutleSs,Rec„_L�9ht._.Sw,_ �tA�L � � . Pirs[20� A4DRESS �� :__.._ �E.ftZ1.�C4,IE_OFEXE49PTIQ'VFRObiWORKERS' TotalJ�o_ Additlonal � � � --' } � .__ _,_..___._CO!�ikE1YSATIQN INSUR.aNCE.. - � CI7Y� _s Tel-No. . . . �.. .. . PLAN CHECK .... . .. .. y_ . .._(This-.6eCtion..need.not be compieted if th�_��ork.imolved � - qaaucAtvT O � - - ._ . .__._ ._��___ ... V �. bY the ' � - - Light�ng FiMiuiez .. �Pirst20 - - - �� � � peimtt�is.-foc,ane hundred dollazs $100)oi lessJ� � - -� � � qooRESS - � � Total No. - A�diuonal - , ,_ - I cer[ify that in the.pe;f,o�7pyanF@_o.f Ihe.H�olk.�ot�uhich this �� � � - CI.7Y - , �� Tel:No. o � r xed Appliances Not Over 1�HP . . - �- _ pertnit is.issued,i sha�l.not emptoy,anv person in any�manner - . -- _ W . . . PE.RMIT ��g��,A�s-� �. U . . ��so as to become subject.to the�{�orkers'ComDensaiion Laws Range.__Heater D.W..._ � APPLICANT �W a ' . - . �. - Oven _.Drver W.M.— ADQREB�.�L`fv�l l.� �•:..�^ gf �. .Z :�. Date A_licant � Top, „�F/qU__W,H._ _.__ _ - _PP . - - FfQ,qd,,.�_F2g� ,_Other�_ . CITY Tel No�7�-�� � ._CID'CIGE TO.�PPLICAVT If,after making this�Certificate.of Disp. �Room Air Contl., LICE.NSE O ""� -��- -� /�� ' �. Exemption, you_.shouLd become sub,lect to-.the Workecs' -�� � . - REG,P1UMBE-R-- � Clasr.� G� �„ -Compensation proyisions of the Labor Code,y�ou:must-focth-. .P,ower Apparams&Large Appliances DiSFRICTNO. � -PRQ.CESSED BY � �vith comply w�th such provisions_:or.this perm�t.shail�be ��Size&Type-HR,KW,_KVA-,or KVAR deemed revoked. � � � - � / . . _ -...UP�to.tincl.-- � - : .1� 4.c -.OviEr�7 io 701nCL F1NAL " ��� ., „ L�,C,E�S,FD,C,Q1V'IR?a.CT0,2S.DECL.�RATION . - DATE ,�,.t,f�,, VAL�Df�TJ.QN ' ..'�..'. "`. .__Over.70to50incl.- . ..f''�,� ,r-.�-<.�.. . , . � PINAd- �.. ` ��.� - I.hereby a�'fum.Shat,l�m licensed unde provisions of Chapter ,_Ovee 50 to]00 Inc:. . 8,,._ . - 9_(commencing with Section 9000)of Div�sipa.3 of the.Busi- -.Over 100 : ��,,- - �� � ._g,gss and 1'cofessions.Code,and mYlicense�s.in:tull focce._and" - - - .- �� 'r effect. _ . ServiCes � � y� _License Nomber���:�"[j��.Lic.Class � � - 0-200 Amp,.Under 600 V . /-.� �Y '� _207 7000 Amp.U,oder..&QO V _ .Cqntractor������� -Uate '�l�'^ -.Qver t000Amp.or OverB00 V . �.�_ � . :� � 4..� -; �.: __..,.,<,,.,, _HOb2E O�.Y,;�LE�t-$U.ILDER_DECLARATION. � Temp.Power Pole&AppurtenaAces--. � I here6y-affirm. that.I am eic.empt from the:_.C.onfractor's .Sign with,.One.�Branch�CircuiY � �� �� °(1 g�,2_g ,�. :�. . LiCense_-Law.fpr..the foltowing reasDn (Section 7031.5,-Busi AdditiOnai SiyrtBranch,CipCuitS- :� . �� . �-�0 � � Q �,� . : ,ness and Professions Code): - , _� ._, , .__, .�. �.-� � Misc,Conduits.&Co�ductars - '� f`�-�m ���C Q ,�� - � I. as owner of the property,will.do the work and the Other(See Complete Fee Schedulel— � � _,�„„�,.�„xtl�cture � not intgnt�eSL p[_of£ered_(tir sale (Section � � � � � �-� m'Z Q J-O� �� . �o44,&usiaessaad.Emfessions Code). . . -�--��--- : , � ___ . ..C9i�SSRUCTION LENDING AGENCY ..--.--. -�-_ . :.� : `�.- O.�{�� �I 4.�4 �. I herebv gtfu'N_[ha[_[here is a cvnstructiort fending ageniy � - for.the p�rfoJ.Snance_o£..She.,work.fox x�hich.this perm5[ is pERMIT FEE �� � issued�(Sea 3097,Ci�.L.). . . . . . � . � (Su@-Total) . .�Letyd�'s,.Na�pe - .pLAN.CHECKING.FEE (One-Foueth Permif Fee1 - - ,.Lendes's.,.addiesg - . PERMiT15SUING FEE � �-�- ' ' � � �' � 7 cettify that_I_have.Yead this application aqd.state..[tiat.the �TOTAL FEE � - � - .,aks�xe wfosmaSion is.correc�.I agree to:comply with all CoiiniY^-^^_:..'. .. _ _..___ :.... . ;� , ��1. . '��. .. . . .pr��a,pcgs.,.and 5[ate La»�s regulating Eleetricat-winng. and � ' " - �--� � " - � " � �� hereby authorize reptssenSatires of this County to enTer upon - the abwe-mentio ed property for inspectio�purposes. -- ' ` '� � ' -- - ,. " • :_ -� . : , ,, - .., :� -�:.��..,.--����'�F.,�����5,��?`1.€�zS�lt�L4�^IG.UAGE ignatuFe_otPermi}tee._ . _Dat '; _ � _ _., _ : , _ _ �;�� ,.�.�;�. - , , : - .. ,. . . . � ..,n ,.� ,, �.- ,.n_ .z�=,����-_ ..,...-_ .. _ . . _. . -.. �:. � � ,: f:� . . .._. . . - ...- - . ._.. . �,- .-,fl .- a�>^..P-'�. ' . . ..... . . . .... , .,...�.. a_....._u ..-�m . _...sT.s-. ... _ . , . . , _ � :... ___. _ .. . . .�. .. _ , .. t �_�.l .,:,�. . :':-.. 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