HomeMy WebLinkAbout1601A (9) .. ......_..-.... ..�. . . . . _ . . ., . ..... ........ .. ....._.... �.,,... , . i . .: . � . - .. . . ,
. . . .. . . . ._ . _ .-.... .., ,.s :..:.. . .. :.:. . ...: .- ,.. �
. . . . . � , . .�.
WORKERS'COMPENSATION DECLARATION :, �� 76A663 10/81 TRICAL� PERMIT
.,. .��'�§BbG, , _,..., �
I hereby affirm that I have a certificate of_consent to.;elf ' , C , , , , , . _. �- � - -- � - � - � -- -
insure, or o certificate of Workers'.Campensation Insurance,� � � � � �Q PP oF LQS AN�NS FOR ELEC BUILDIN�G ANti�SA�EfiY '- �
or a certified copy ihereof{Sec.380Q Ca6.C.)
P❑olicy No. Company. . .. . . FOR APPLICANi�TO FILL IN... .. . ..� - J08 ��� - ` �, J�I
Certified w �S hereb fumished. EACH NO. FEE ADDRESS (
pY� Y New Residential Bldgs.&Pools
� Certified copy is filed wilh the<ounry building inspeo- 1&2-Family;Sq.FL 5 = F LOCALIiY - � �
tion depariment. Multi-family Sq.Ft. NE,4RESi `r
Residenfial5wimmingPools OWNEROR v"t b�s IK.G
Dafe �Applicant . . fIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS /� 1C �
Outlets:RecL�Light�Sw.� MAIL ,j, �
� COMPENSA710N INSURANCE���'���-�- � - � G� A�DRE55 y!i C
First 20
(This secfion need nof be completed if The work involyed by Total No. Z� Additionoi �" CITY �rce.� � � Tel.No. f
fhe permif is for one-hundred dollan(f100)or less.)
PLAN CHECK
I certify ihat in ihe perFormance of the work for which.this PPLICANT W li.e,f�
permlt is issued,I shall noi employ any person in any manner � - � �
so os to become suble���o the Worke Co p 't' lows. Lig�g Fiztures Firsi 20 ��`5 A�DRESS ��,
Additional
otal No.��_ CITY Tel.No.
Date Applimnt , � Fixed Applionces Nof Oyer 1 HP pERMIT -
NOTICE O PLICANT: If, afi r a irig thfs ertifimte of APP�ICANT' — �C�Y�C�
Ezemption. you should becom su6ject to ihe Workers' Range_Hea�er_D,W. _.
Compensatlon provisions of the a6or Code,you mus�forih- Oven _�ryer —W.M.� ADDRESS ',��� n C
with comply with such provi ions or ihis permit sholl be Top —FAU —W.H._ ❑iY Tel.No.� /
deemed revaked. � e t '
Hood _Fan �Other_
LICENSED CONTRACTORS DECLARATION " UCENS OR
I here6y offirm thot I am lirensed under provisions of Chapter 9 Disp. —Room Air Cond. — REG.NUMBER L Closs. ,_
(mmmencing with Sectian 7000)of Division 3'of iha 6usiness po,,�er Apparatos&Large Applionces DISTRICT NO, PROCESSED BY �,
ond Professions Code,and my license is in full forcepnd effed. J � O.
f� /�7 Size 8 Type HP,KW,KVA,or KVAR ! � C�.u,t_,<,� U
License Num6er-���—�ic ClassS��L� Up to 1 IncL � pA EL %ry`! �
,/� ,r`/ � � Over 1 to 10_Ind. U• � 7,*d y' VALIDATION _ Q
Conlractot��� t�/1'�U��- Date �- � Over lO to SO.Ind. F
❑ FINAL �
f am exempt under Sec Over 50 fo 100 Inc. BY �
Over 100 y
8.&P.C.for this reason �
'
. . . . � Services � �- CC&Panelboarfls "�
�ate: , . .. 0-200 Anlp!Under 600 V � { f'�
Signarure - - ,. , ._ '_ 2 Amp.Under 600 V
❑ Over 1000 Amp,or Over 600 V
Exemption for Reg.Maint Elect.
SINGLE FAMIIY Temp.Power Pole 8 Appurtenances `� ��� F
HOME OWNER-BUILDER DECLARATION, Sign with One Branch Circ�it �e e s e o�
I hereby affirm thot I am exempt from the Contractor's License � qdditional Sign Branch Circuits
Law for ihe tollowing reason (Sedion 7031.5, 8usiness and f a c rj O,(5
Professions Code�: �
❑ 1,os owner of the praperty,wi�l do the work and the Misc Conduits 8 Conduciors • e.e�`rj,[rj�
siructure is not intended or affered for sale(Section Other(See Complete Fee Sched�le)— �
7044,Business and Professions Code). ., ��� �_��
CONSTRUCTION LENDING AGENC,Y„ , , � � •�
I hereby affirm ihat there is a construction lending agenry for . . � � ._..-
fhe performance of the work for which}his permit is issued PERMIT FEE ;Sub-Total) � �(/3
(Sec.3097,Civ.C.1.
. PLAN CHECKIN6 FEE
Lender's Name , �- � ' �""'- ' pERMIT ISSUING FEE e^i .�
Lender's Address
I<errify iha�I hove read this applimtion ond s�are ihot the TOTAL fEE �G. ���
obove informatian is correcL I agree fo comply with oll Couniy � � �-� - � -' �-" �� - "�'�� - ����"� "-" -��- '��"����"' � ��� -
ordinances ond Siofe laws regu�ating Electriml wiring,and
hereby authorize representatives of this Co nry to enter upon
the ove- ent' ne r perty inspec' n purposes SEE REVERSE FOR EXPLANATORY.LANGUAGE
� . ...... .. ._ ... .. .. .. . . _ . .. .
V
�ignatur of Per ittEe' Dat ...�. /a................_...__._,��--.-.,,.,..w.,....,,.....m,..,,,.....�....�..,m9-a<...��.....F,....e_,..a - s..,..,�,-,.�...m�.�....�--�...n...
. ' �APPROVALS oAT�N ECY � � �- OWNER-BUILDER DECLARATION
SIGNATURE
?EMP.WJWER POLE � � - � � hereby affirm thm I am exempl from the Controctor's
-�-� ' I.icensa Law for ihe following reason (Saction 7C3i.5.
UNDERSLAB WORK I /r Eusiness ar.d Prof�ssions Codzj:Any city cr ccur.ty which,
RQUGH CONDUIT � ,,; I reqViros a permit to construci,alfer,lmprove,demo(ish,
I or repalr any s}rucfurm, prior to its issuance, also re-
� � � iNIRING ,� ��- � �. qufres tha appllmnt for sucb perrnit io fi(e a s7gr.sd sFcr¢-
� . � FiX?URES - i � i menf fhQP he I5 licensed�ursuont to t6a provislons of the
, _� Contnactor's L.Icense Law(Chapter 9(commencing wifh
" POWeR AUT'riORIZED ' Section 7000j of Dlvisior 3 of the Buslness and Profe;�
, i sians Code)or tha'r he is ezempf ihereFrcm ar,d the bosis
�� � UTIl.ITY CO.NOTIFIE� for 1hs alleged exemption. Any�violatian of Section
FINAL n � . 703I.6 by any applirnnt tor a ps•rmir sub;aots the appii-
Gn.:`ssr oa�ranE cant(o a ciril penalfy of no�more ehan five hundred
� NOTES dolfars(5540).:
- � , . , _ � ❑f,os au.•ner af Phe property will do the work,ana
ihe strucfure is not intended cr offered for sale.
. . . . . . ... . . . _ . . ..._. .. ,
- . . � . - . � (Sec.7044,6usiness anil Professions Code: 7he Contrac-
� � " tor's License Law tio��s noi apply io on o�vner of property
. � . , �,� : , , � who bui(ds or improvas fheraon, and who does sucR
work himseff provided iho4 suth Imprnvemen}s cra nof
� _ � � - �� �� � � � � . � infendsd ar off�red for sale_!f,however,the building or
- Improvement is sold withir,one year of compleFion,th¢
. . � owner-boiider wfll have fhe burden of proving 4hot he did
^ � not boild or improve for tFa purpose of safe.J
I am exempi undar Sec .
B 8 P.C.tor tnis reason
Dote
Owner