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HomeMy WebLinkAbout1054A (5) _.,,,. _ ,.�.,_.�_ � .�., �... � .,� �,. �..�.:. �.,>.:��. � ..,..�. �..,,���.� a ,>..;;.. �:� , ; . .���,���, .�.,,�,� �.��..�.� � 4VORKERS'COMPENSA7fON,DECLARATION - �6a663� loiat �. APPLICATIOi�l�FOR �ELECTRICAL F�ERM,.IT � ��� ` � -� ' � orha certif edircr ihahereof Sec c380f'cat b oC,ansenr to self �E�806'F� "� v P ✓ ._. ., .,,Cb O�RAPPLOICANOS�hN G"EL�S......,,...�_..._.. �os �BUILDING AND�. ,. � _ ins e or a ce tif cate of W kers C m enwtion Ins'r6n`ce;� " (f � SAFETY �r � ( � } . . . . . . . . . �r �^ � /� ✓'} j� PolityN�L��'�/l ./J�.panY.. f�J�sT '� . S�G� . / � CG�-efJ� � � � ... ....:.:.... .. . . ...�.. ...�� EACH NO. fEE ADDRES � � Certified mpy is here6y fumished. New Residentiol Bldgs.8 Pools - �� � �i �._LerPified mpy is filed with the county building inspe 1&2 Fomily,Sq Fc 5 = S LOCALITY� �� ON� �� NEAREST �� t on departmenr. � .� Mult fpm ly Sq.Ft. . CROSS ST ��� � ��. � �'��, -: ,.-L���:�2(,(�c� /� � Res denhnl Swimming Poals - % Date � -ApPlican.l'�� � A.p . OWNEROR � � 5,�� . + E � • . .... 1� FIRM NAM PV . � - CERTIFICATE OF�EkEH1PTION FRC7M WORKERS' � � �M:41L� � � � ��"' ' , . . -� ,,._... Outlets:Rec_Light_Sw._ ���`�..T�.�/�R� /� . COMPENSATION�INSURAI���"���� """���� � a.DDRE55 �s . :� . -., firs120 ...... . ..._.........: ��(This secTion�need nof be complefed if fhe work�involved by - CITY�i �/ F�� Tel. L ,s^r'V �_� the permiT is For one,h�ndred dollare.(5100)or less.) To�al No, Additional p qN CHECK " � -- ��- i I�certify that in ihe performance pf ihe work for whlch this � ...._. .,. ................ APPUCANT ' �permif is�issued,I shall nof employ any pe son in any manner� --...-.,.�-- -...-..--...-.. .. ,.._..�......,.._ � so as to become;uhject to the Workers Compensat n Lpwg. , Lighting Fixtures . First 20 ADORESS� '�' � Additional ........._._.... ., ._.m_..._.... .._.._. , .... � _..�.... ., .. . . .. � � � . Total No. CITY Tei.No. �ate ` � A licanr � �.�( . j , . .Np , . � � � �,..-_�., Fixed Appliances Not Over 1.HF PERnrtiT ��� , ; NOTICE TO�APPLICANT; ,I{, after mok ng ihrs Certif cate of _. -� APPLiCANi.!yj. /n7 Psa� �' Exemption,� you should become 5u6�ec� �o ihe Workers' Range_Healer_D.W. _ y' •c Compensafion proJis�ons o4 fhe La6or Code,you must forth- Oven _Dryer _W.M...._� ADDRE55 ' a p� �'� - ; �w th comply w�th such provsions or ihis permit shall be . Top �FAU „—.W.H.— � � " ,deemed-e oked Hood _Pan _Other_� CITY TeL� � s.`'�'�- '.� LICENSED CONTRACTORS�DECLARATION ��� LiCENse oR- '� '�-"� "�� �"'"'",. I' � �' "<' -'� -����� -������ Dis Room Air Cond. ' I h reby affirm thoi I am licensed under provivons of Chapter 9� P' — —� REG.NUM6ER �� �� Class.� � . (rommenung w ih Section 7000)of Drvis on 3 of�the Business � DISTRICT.NO. � � �� ���� PROCESSED BY � � � end%ofessions Code,and rny 17cense is n full force and effect� -" PO`"�er Apparatus 8 Large Applipnces I /� � �>'�- ' � �� . �-��- �/- t �� ��� � �� Size&Type HP,KW,KVA,or KVAR- � � � Lice se Number �� L c Clas;� Up to 1 Ind. F�NA� V �p_7.�t�r AJ� - Over 1 to t01nd •� a .. ' -Confrac't'oi ���� r���`�. �aie . . .. DATE � �ys VALIDATION..... ..� : ❑ .... . --.-. .. Ove 10 iq SO.Incl, � .. -....-, V ; ����-- FINAL � � I am exempt under Sec. � Over W to 100 Inc. BY , w i� .. .. ,._.. .. .. . . . __... .... , [. B&P.C.for this reason Over 100 �- "��J y _' �.. . . . -...:: ..,. :_ . . . . . . �', . . ___....-., .,_. . ..,._ . ..._� ...... ...._. � �- ��po�e Services,�Swbd.,MCC&Panelboards ► � s ; '� - .. . :.•... . •..,.. 0-200 Amp.Under 600 V '. . � �Signature ��- _ . . 201 -1000 Amp.Under 500 V ❑ � � -��� -- �- � .. .� . . Dver 1000 Amp.or Over 600 V � :- Exempt on for Reg.Ma nt Elect I � . �SINGLE FAMfLY � Temp.Power Pole 8 Appurtenonces � z� �5.L}� � � HOME OWNER BUILD.ER pECLARATIQN � � � Sign with One Branch Grcuit i{P o 0 o t G �� I hereby affirm thpt I am ezempt from the Contractor's L cense �_ qdditionol Sign Bronth Crcuiis Law for the following reason(Section 7031,5, Business and 1 e °�e s e Professions Code): � , , � � ' � � � M�sc Condui5&Conductors � -.,.., x � . . I,as awner of the praperty,will do the work pnd the � -� � �v l;���J�� �- ; . -srruct�re s not infended or offered for sale (Section Other(See Complete Fee 5<hedoleJ— ► .. .. . . . .. ,-, . _R J �� 7044.8usiness�-and�Professions Code). �� � - �,� '� _� . ��� . , p� � l.O { � -� :�CbNSTROCTION LENDING AGENtY ���- �` �-. ; -I hereby affirm that ihere s a co st;uctio lendi,ng agency for"� . _ .. . . _ , ...._._.. ..:........ ihe performance of.ihe w k f,, .hi h ih.s perm t s issued PERMIT fEE. ,. (Sub To�al) a..ty� v� (Sec.3097,Civ.C.). - � � � � . . . - � � PLAN CHECKING FEE � Lender's Name � �j , �� �� PERMIT ISSUING FEE . �GX',•'�� ! Lender's Add,ress � � . I certfy thol I hpve read ihis app�iwton and�state tha!ihe,�� TOTAL FEE. �� -5�3 above informpt on is correc�..l agree to comply with oll County � - �� � � �� �-��-----� -•�---��-�--- �-�->�n.,.....:. ...-.. ,.,.. „ .....�,.,;. . . ordinanceg and State.lov✓s regulating Elecirical.wiring,and ����u�--���� �..���~. .:.�...� • .�.., .,.,..� �� herebyp. o z e e �tatives o4 th s County to enier upon� . � � � � �� �� . . . . me � d o ert forinspechon purpases � . _� ��� � .� _�,,a'' SEE REVERSE FOR EXPLANATORY LANGUAGE ��. - : � . .._.:. ......... . ...,._... . .,..._... .. ......_ _.......,. _...._.. .... . . . �, .^ . . _ .__.�........ � f` . � i -/r.J s� . lure of P rmiti.ee . ..Oate .,.., ....... , . ,_.,,, . .... .. . .... .-.. .... . .�.. . .. .. . _ _ -- _ _ __..__ .._ . � - � �� �' �` �APPROVAlS. oATE �' ' R � � bWNfR�BUILDER bECCAkAT�ON . . �. . SIGNATURE - . � � TE/.AP.FOWER�POLE ��� � - � I hereby affirm that I am exempt fro�m the..on?racior's License Law for ihe;ollowing reason (Saction 703:.5. � �� �. . UNDERSLAB 4YORK � � Busin�ss and Professions CodeJ:Any ci;y or coun;y which � . ��� -ROUGH CpNDUIT� � � � .requ'r.�es o permi5 Fo consPruct,a(ter,emprove,demolish, .. .. .... . . �.� . - �� or ia'palr�bn'y s3ructure. pfior fo its issuonce, afso ra- _ . . WIRiNG �� quires4heopplimnttorsucbparmittof)leas;gnedsfa:n- '�� ��� �� �� � FIXTURES � �� mmnt fbai ho rs llcensed pursuont io 1ho provisions of the - �� ' - '�` � . Corsf�ac3or's License Law(ChaFfer 9(commencl�g wi4Fi �� � -- PQWER AUTHORIZED � � Section 7Q00)of Divislon 3 of the 8usinoss cnd Frof�s- sions Cods)or That he is exempt tnerefrom ond#he-bosis � � � - UTIIIN CO.NOTIFIED {or the alleged exempilon. Any violation.of Secfion . F1NAL � -�� . iO3}.5 by eny vpplicant icr a permlt subjects the appii- � �--� ' �- '�, ic,fer ars , ronf . cant to a civil penalty of not more fhao 9ive hundr�d . . ... . .. .. . � . . .NOTE$ . . .,.. ..... : . dOII015�SOQ�.: . � .❑�I,as owner of fhe property�,vill do the work,and �'� -�� �' ' .._.......,fhe sirutture is not intended or offer�d for salz. .. � . �. � � � � � ' � �"� � -� (Sec.7Qk4,9usiness andProfessions Cnde: Tfie Contror ...�. .. .. .� .._ � . • - , � ' � - .....,.......,tor's License Law does not apply to an owner of property �� - ' - � � - � � . � • � � � � .. . who bullds or improvss thereon, and who does su<h .,. � - , � .,.._._.,.work himself provided ihat such in,provements ore not ..:-"'. . . . . .... . . ... . . ... ...� � . . .. . . inten��d or of4ered for sale.!f.however,The building or . - ,.,.,._s...,improvement!s sold wi;nfn ane yecr o3 complefion,the . � . �� � . , . . owner-builder wi!!bave the burden oi proving thaP}�e did �� �� � ��� - � ` � `� �... not build or improve for the purpo;e of saie.) . .:. .. . .. _ . . ._.. . . ._....::_..,�.:>..... . .... ... .. .. . ...�'.: � . . .�. .. ,........._ � � � _,. I am exempt under Sec � � , � �^^-•°�B&P.C.for this reoson— .. . . . . .. ._ ....,._... . ..._....... .,,..__.............:.....�....� , . ....:...... ...... . . . . � . . .. - Date ._. - .......n.Owner_:.........._.�...�,.. .. . , _ ..�......_....�.r...».._........_.. � ._.. ....... . . ... . ,� , . ., ....�.. �...-...�.. ..., .. .....�:., .� .�,...,,: .. �x �•:f...�: .�wi,.v'....�:karz,. . : . ..... ,._.»iktw. -i::x�..v. ,s;;a.. '..;.: