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Home My WebLink AboutNo Permit Number � , �� WORKERS'COMPENSATIO(4.�ECLARATION ,- 76A3ti3� 10/81 ..�APP�LICATIOIV�FOR ELECTRICAL PERMIT � .. ••�.•.. CE Sd'6G- � I hereby affirm that I hove a certifimte of consenf to sel4 -- � � � �°-•� - -� ^ �� -�-•�---�� -•�� ,- .insure,or o certificate of Wo kers__Compensation Insurance, ' � � � �" �� COUNTY OF�EO�'�KIVGEY�S ' � � " �' BUl1bTNG AND SAPETY - or a'certified.copy thereof(Sec 3800,Lab.C.) � - ,� �P❑olicy No�19��2�.23Company...�TfiTA . :., .. �..... � FOR APPGCANTYb..F1YYTN.:..__...__ . . :.....,-.y...,.. JOB . . .. . ... __....... n Ceriified co 's hereb furnished EACN� NO PEE ADORE55 Lpt, . 3,rj -. , " � pq� y New Residential Bldgs.8 Pools "��"�� ' � � i a 2 Fam�i 5 Fr. 21.42 $ — § �OC4uTVTR #35742=3005 Diamond Bar -. g Certified copy is filed with ihe rounty building inspeo- �Y� q' . 'NEAREST� � � � � � �� tion depdrtmeni. Muhi-family Sq.R. �CRd55 ST. . � '��'� �. � - �' �.. , �� Residential Swimming Pools OWNER OR ' �� `��-��' -�- �are £i/13,lR"� ,4ppl can+ " '� ic FIRM NAME M,J, Brbck & 5ons � � � CERTIFICATE OF EXEMPTION FROM WORkERS .,�,,,... putlets�Rec_Light_Sw. „_ MQIL� . �� -� �� -�"�� ' 'COMPENSATION INSURANCE�„_:, � � . 3 Q� A�ORE55 1698 Greenbriar L11. #224 . :.� ... ..._ First20 � .-;..�- .. ... . . ........ �(Th�s secfiodneed nof be complefed if tbe work invol4ed by Tatal No. C�TY BTOd Tel.No>rz9-$17� the parmif is for one hundred,dollq,rs(SIQO)�or less.)� - � Additional - , . � PLAN�CHECK .. . ........... ......_....___.... � �I cerfify�thaf�in ihe performance of the woi,k jon c�h ihis„_„ aPPtICANT � �permit is issued,I sholl not employ any person in any manner -']5 �� '��"� ��"��"��"��- so ds to bemme su6ject ta the Workers'Compensation Lows. Lignting Fixtures �. Fi�st 20 � ADDRE55 . . .�. ..,. ... ... . Additional . . . . .... � � � � �� . - �- . � Total No. �- GTY Tel.No. , Date . �.. .� Applicant � ' . ..�� ......_ Fixed Appliantes Not Over 1 HP PERMIT .. . . ...... .. .�...."....,... � � TICE TO APPLICANL If, after making this Ce tif�cate of APPLICAN7�' �� ' � � ��nption, �yov should.become,..subject lo ihe Workers'. „ Range_Heater_D.W __ .. . � npensalion p o��sions o4 ihe Labor Code,you mus�forrh- Oven _Drye —N'�.M�.� � ADDRE55�3�0--S �R2SB O� with comply with sucF. provisions.or rhis permif sholl 6e Top —FqU .-�-W.H.— �� -�� '""' '"� ` "��" deemed reyoked Hoad _ GTY POIROIld Tel ri�27 p936 . . . _Fan Other_ � - . LICENSED�CQNTRACTORSDECLARAiION ,.-�� - � OLICENSEOR �� ""- "` "�""- '"'""'"""'"' � � � � � -'-' � '��-'�� Disp. —Room Air Cond�. — . � REG.NUMeER 153378 . _, aa:s.-C-10. I hereby a4firm ihat I a licensed under provisions of Chopfer 9 � . . � � (commenc'ng th Section 7000)of Drvison 3 of the Busmess , � DISTRICT NO. . PRO ESSED BY�� - and P ofessions Code,and my license is in full force and etfect,.,.: Power Apparatus&Large Appliances �f � . �.'. ' -. .- � � Size 8 Type HP,KW,KVA,or KVAR �� Q License-N�mber 153378 ��-�� ciass"C 10� � uP ro 1 Ind. PINAL V . .... ..... .... . .. ...... ...._ DATE �. '. . . -.. � �. . . Over t to 10_Incl. . ��--'/Q— VALIDATION � � Contrador- R12CtY1Cd1 Date 8�83 �� o�e�io ro so i��i. � -� �� ' .. � ❑ - ,... - �, , ... ... . . .. FINAL lJ I om exempt under Sec. Over 50 10 100 Inc BY /�''T�' � ... . ..... ..._ . , . - � 6. - � � �� Oyer 100 � � B.&P.C.for ihis reason � �� " � � � _ . ... ., ..,,..,...,. ► � � � � � Dofe '�� Services,Swbd.,MCC&Pdnelboards_ -' '..� ....... .. ......, ., ..,....._..... 0-200 Amp.Under 600 V , � �Signature � , � � .� 201-1000 Amo.Under,600 V � . .. _........,_., � ❑ � � � �� :. : . � �� Over 1000 Amp,or Over bOD V Exemphon far Reg.Mo nL Elecr. ! - � � SINGLE FAMILY � � � � Temp.Power Pole&Appurtenances � ,r�`'� � � � HOME OWNER BUIL�ER DECLARATION � Sign with One Branch C r<uit , „ �, s ,;� !"'�reby affirm iha(I am exempt from the Contiactor's License qdditional Sign Branch Circuits •�for,the followinq reason (Section 7031.5, Bvsiness and � ., �. -.- � Yrofessions�Code): � � ��F��'" � . ❑� I,os owne�of the property,w II do the work pnd,the Misc Conduits&Condu�tors . _ g ,,l "J - sirudure is not intended or qffered,for sale (Section, Other(See Complete Fee$chedulel_ ► � - � 7044,Business and Pro4essions Code). � . . . ..... _ � � C '�j ' � � �. CONSTRUCTION��ENDING AGENCY � � - - the r erformlanceh pf�heewo k forswh�ch Ihl sntlerm�gs rssued .. PERMIT FEE � (Sub-To� p Y� p . . tal) 96 . � (Sec.3097,Civ.C.). � � - -� � - . . . � � PLAN CHECKING fEE � � _� � Lender's Nome ZO SO - - .'-�"..' ` "��•"`J"' pERMiT ISSUING fEE Lender's�Address � � � � � � �-'�`"� ' ' �""�� TOTAL FEE ZOG�S3 �.� I certify rhat I Fave reod this applicatwn and state thot the above informotion is correct,I agree to comply with al!Counry . . . . . . .----,....-- . �..�....-.__.. ....�......:.,,..._._....... . . ._. .. . .._...._. . _,.. ... _.._.... ._..... ... . � ordinanres and Stafe lows,regulotinq Eleciriml wiring,ond � �. . hereby uthorize represeniatives of ihis County to enter upon � �� - � � � � � - - ' � � - the� e- f ned property for InspeUion purposes. - � � � � . - y° � . �- SEE REVERSE FOR EXPLANATORY,LANGUAGE ,, ,. , , , F /. `_-- 8/8/83 . _ . ,: _ _ . Si e of Permittee � . ......Date ...:...... . .. .._,.., ..,,�.,,,. ,..:..,;.. �,,..:.. .. .. .,., . .... . .._. .. , .. , _. . . _ .. ..- -... �:.PPRWAlS DA?E ��i�� ..:� . ... .. . .. ,:.�. OWNER-BJt!�EP.DECLARAT(ON�.� . ,:`:.� .,. .. .. ._. .._ � SIGNATU@E . . . ,.. . . . . . -�.��'� '�-----•�'�� --��- 7EM��."F01WER POLE�� ,. � : � ' - . � - I�hereby affirm tFa{I om exempt from the Controctor's � � �- � -� -- � � . ` �-- License Law for the 4ollowir.g reason (Section 703i�5, _ _ - UNDERSLAB WORK-_ . � Husiness and Nrofesslons CodeJ:kny city or covnty whicb . RQUGH-CON,DUIT� � � regqires a permitJo,construct,alfer,irpprcve,demolish, . . . . �� or�repa7r ony sfructu.^e,prior la "N.s issupnce, vlso re- ....�. . WIRlNG.. .. - -� ,� � , qulrestheuppLcaniforsucfipermittoiiieasignedstate- � ment that ho is hcenseri ursaanf to the rovfsions o7 ihe � � � PIXTURES - ��-- � ; �Cortfrac}ori Litense Low(Chapter 4(c�mencing wi9h ,.. ,.,.- . ,. . � -� � �� POWER AU?HORIZED - Section 70Q0)of Dlvlslon 3 oi the Business and Profes- � . sions Code)ar ihat he is exempt iharerrom and ihe bcsi� �� ' - � � - UTILIN CO.N071FIED � {or the alleged exemption. Any,viola�;on ot Sec9lan �� - �� FINAL n c7 7035.5 by ony appiitant for a permif subjects fhe appli- Gnfer on-_tvenf _: , cant to a civil penal4y of not more ihvn five handred . ' - � - �� NOTES . - � dolfars(350Q).: - -�� - � ::�:_ ��- � ❑1,os owner ot tha property will do ihe work,ond � - . �....�_... .. � � " � ' �� ihe shucture is nof intended or offered for sale. � � � - (Soc.7054,Business and Professions Code: ihz Com. ,- ,^��: .,�- � ., � � ... �. � � - . ...... . . . .. . � � lor's License Law does nof apply fo an owner of propertq �.. . -�- - ��- ��- -� �� . �..." ��-'. . � _ � . - � wfio 6uilds or improves therean, and who does sud� � - ' ' '-�'"'' �� `�� .. work himself provided That such improvemenfs are nof �"-�� - �-�� " � � � �-��-'�- � � � � °in�ertded or aifered for sale.!f,however,ihe building or - � improvemoM ts so7d within one yeor of complefton,!ha . �-� - - � � � . � � � . . � owner-builder wll(hove(Fe b�rden of proving ihot he did � �� -� � � � not buifd or improve!or th2 purpose of sale.J � � � � .. . � �� -��"_ � .. . .. .� .�: .. i am,eKempt unciar Sea. . . . . . . .. . . . . . . . ..., . ..:�:..... ...:. . _ . . . .�,.. .. .. . _ . �� . . . . . . .. . .. 6&P.C.fo.r this reason -_- e.^ \ . . .. .... . .. . . . . . - . ... . . .. ��., . ��:. � � � � � Date . . � � . - Owner � .... . . .. .. . �. � ... - . _ .,.. . . .. . ` . . _ . .. . . . .