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HomeMy WebLinkAbout1369AWORKERS' COMPENSXTION DECL�RATIOh'-- -_P6.f11® M� I hereby affirm }fiat I have " a cerpFcate of consent to self _' COUNTYb CDS AN ELL$&UILDfNG - - - - ANTS SAFETY insure, ora certificate of Workers' Conipensatiori Insurance, or - - acertified copy' thereof (Sec. 380x, Lab. C.) -� Policy No -- Compan3 FOR APPLICANT TOFILLIN-- - _- -- - - p - JOADDRESBS 1 -- ,. _s New Residential Bldgs. & Pools "- - EACH NO, FEE - - ❑ Certified copy is hereby fur - - nished. 1 & 2-Famity,Sq. Ft. -- - S — S LOCALITY ©j ❑ "- - Certified copy is filed with the county building inspection i Multi -family Sq. Ft. - RAREST - CROSS S7 Residential esidential Swimming Pols - OWNER OR - - Date ._Applicant - - _ Outlets:_ Rec.1-Light � I S,,,.`jc FIRM NAME �] MAIL - -:- - - Flrsf 20 ADDRESS - CERTIFICATE'OF'E7i:FIv7P'ffp"ti I"F`#OM-iirr O"R'f{ERSt`-'`- Total No: -J I Additional - CO;viPENS.4`ITON INSY7RdNCE _ - - CITY Tel No. O' av>. -- (This section need not be-complet'e 'I the wvoilc"mvo(ved- -° APPLICANT - --- -- O by the permit is for one hundred dollars (5100) or less? Lighting Fixtures First 20 - - -. ADDRESS - �- -_ - ' ' ._ '--cc Total No. Additional - I cert if that in the y performance of the work {or which rt fs - - Fixed Appliances Not Over 1 HP CITY Tel No. - 0 permit is issued, I shall not employ"any person in any manner - PERMIT so as to become subject to Compensation Laws. _ _ Range_ Heater-_ D.W. ! Oven `_ Dryer _ W M. — - _ _ APPLICANT el<- V ltl IL - us - - - ADDRESS - - -- - - Dare _ Applicant G _ FAU W.H ' - '_ - Hood —Fart -�—Other_ CITY - Tel No. - - NOTICE TO 4PPLIC AT'T Yfafter making this Ceriificate c;r _ Disp. Room Air Cond._ LICE O LICENSE -OR Exemption, 1 p you should become sube t to the^Workers.. _ - - - .-..:-. .-...._ NUA%fBER --- "-`Clas's », ,, Comperisatwn prowasions o#'tCie Labor'Oo�e ou must #0_,F?5t Power Apparatus &. Large Appliances DISTRfCTN0. - "` PROCESSED BY - with comply with such provisions or this permit shalf`b6- doomed revoked. - - Size & Type HP, KW, KVA, or-KVQA Up to 1 Incl. _ lc�[.cP-�•� -FINAL LICENSED CONTR`>CCTDR-Sb`L21;AiYeCT[O'BI".` "- Over 1 To 1-0 Incl. _ - - DATE Over 10 to 50 Incl. : f VALIDATION - - -- hereby affirm that I am ItcenseiY under provisions of hspfer F. I (commencing with Section 7000) of Division 3 of the Busi Over to 100 Inc. - Over 100 FINAL - BY - fess and Professions Code, and -my Ireense'15 iii full'ftitce andffecL - ," Services- -- - _--- License Number - - L c Class 0.200 Amp. Under'600 V _ rt 201-1000 Amp. Under 600 V - - - Contractor -- Date - _ Oyer 1000 Amp. or Over 600 V,.-_-_,- - HOME Oti4'13ER $"LT77;i5�K I)L2C:Q12'�'Y"POR"i. Temp. Power Pole & AppurtertanGes-' I hereby affirm [hat 7 am"exempt from- the Contractor's `- -Law Sign with One Branch Circu if,- _ Additional Sign Branch Circuits License for [fie following reason (S,eci on 703 L:5; Busi-` - nessarid Professions- -' ❑ -` 1. as owner of�the properi . he work . will do'tand the - - . Misc. Conduits & Conductors Other (See Fee Schedule)— ,) 3 4 A structure is not intended or offeredfor sale (Section _Complete - 7043, Business and Professions Code). ` - - - - - - - -- - - o - e s o � Q - CONSTi?L*CTI'OIs7 CENI)fN`ts _X'OVN`CY `-......, '. ` '- I hereby affirm thatthere is a- construction tending agency - - j •- • 3, 23 0 - for the performance of the work for which this permit is - issued C.). - -- PERMIT FEE _- - -- - -Total)-Total)-- (See.,3017, Civ. - - - o.®- e 3 2, 3 Lender's Name - - PLAN CHECKING FEE (One-rourth permit Fee) 0 1.28-82 LenS der'Address '- PERMITISSUINGFEE _ - _ I certify that I have read skis -application�and'stafe iliat the TOTAL EEE - X V bove information is correct. I agree to comply with all County ordinances and State taws `regulating - � -• -= _ ' --- `- � Electrical wiring, and � hereby - - - - ._ �_ _` -- authorize representatives of this County Yo-epter upu7t e a e mentioned property for inspactio -purposes, SEE REVERSE FOR EXPtANAT0ItV fXXGifA66t s' +Y-!� �LCf ✓6' GG �-GSpL'r�� �� wZ.�'_[7 �. - - ., - - _ .._ - - Signature of Permittee Date- _ _ - _. -:_ . OWNER-NIDER DECLARATION, _.1 hereby aft7_T.1 that Ian esernptfron the. Contractor's -. • _ INSPECTOR., _ Lie nse Law :_os the following reason tae lion 0313. - APPROVALS DATE SIGNATURE Business and--PrGfeswns Cadet -.tiny city or county - TEMP POVVF R - POLE ._ whichr¢uirET a Permit_ to CorlSiruCt ¢fret �irrp Gv'e, ' - _ d¢mbtlStt or repair ars' dlrG cWre pYea to -its IsSa�t'C': - UNDERSLABWORK J. also r quie, the. applicant for TV h permit to file ,a ._. ..... R OUGry CON D+.i4TF r • t�J�t '�tL — - -? ne sta`e ¢nr that h¢ is tzren�ed ur.,uan. i- a- rk -S G ,t P c�-5. �9 1TOVA4EO CS of the Contractors License Law /f,)laYte: g : WiRINI - . -. t i -_'Q rPTdeacfbg. w�irh_ 3¢C'ttbiY-..)Vli(7j of ­Division .3, of-th%¢ -. "r�SXTUt"'il;S ___ : _ `_. -: -. .. ... ... . . _ - - Business ana'-F3'O esgions fbde) or that PC is exempt :. [f82refr6 3 r!c' ;he baSti'si�Y it¢ of E ¢d CxCmptibri.-Any _POWER-AUTHG RJ ZED r -- _ - _ _ _ _ oto.¢ eon of Section 7031.15.bjany applicant for permnr- - Srd'F.JCCts the applicant to a CiYi1 p¢na{Il' Of not 7n0Y¢ than • ;- - UTILITY CO. NOTIFIED I- j fau urea dofta;s'(5500).:-.- ,:_ FINAL :_._.. 'g� ¢�i :�!.• i ' ` L'I F, s t wa-eer of tie piope=ty -,till do tha wori;. and _ _ ._ _ the structuse.is not intended oz offered for sale. - -._..NOTES __-... : : - ..... _ ...(See 7044, Business and Professions Code, .:The Qon- _ tractnY4 Lieenwe Lowdoes not apply to 9:i owner.: of -pre ee vireo buffds o. improves: thereon, and who does _ .. _.. _ :'..-reek work.. himself provided that such improvements are riot-inrenceG OF .elle>ed' o> saie.-3f,- however. the 'building or improvement.: ,is sold- within one-year b -rhe owner -builder will have the bNrde of pr:ryrn3.-that he did. not bu,'f'-Gr %-npr2:;e_ forth i am exempt t a er d, .--B & P.C.:or this-Teasor - Awrer