HomeMy WebLinkAbout1375A �� WORKERS'COMPENSATION DECLARATION �bn�63 i0iei APPLICe4TlOM �QFt ELECTRICA! PERMIT
I hereby aff�rm that�have a cer�ificate of consem ro se�f �E-� �
� msure,or a certificme of Wo.kers'Compensauon Insurance, COUNTY OF LOS ANGELES BUILDING AN�SAFETY
or o certified copy thereof(Sec.3800,Lab.C.)
��„rvoC25859577.�om��y I� FORA�PLKANTlOfMl1N ADDRES Lot 10 0 Lisa Ci011Yt
Cerfified copy is hereby furnished. EACH NO. FEE
New Residen�ial Bldgs.8 Poois LOC11L1 TR�42586 iamond Bar
� CerYrfied copy is filed with ihe tounty building inspeo- I 8 2-Fomily,Sq.Ft. 1 S(j3 3 — E
- tion deportment: - Muiti-family Sq.Ft. — NeAREST
CRO55 5T.
$�2��86 ��T�� McGee Electric Res�dential Swimming Pools
Dote qppliconl OWNER OR
FIRM NAME Andea G
� CERTIFICATE Of EXEMPTION FROM WORKfRS' Outlets:Rec_light_Sw._ ���
COMPENSAiION INSURANCE ADORE55
ThH��eNvn need not bs eom First 20
� ( pfefed i}fhs work inwlwd by Tota�No. Additional CITY �yina CS. Tel.N°�J67-J$41
� th�permi�i�for one hund�ed delbri(SI00)or I��e.)
1 certify thm in�he performance of ihe work tor which this PLAN CHECK
permit is issuad,1 shall no�employ any person in ony manner AGM�CANT
� so as io become subjec�ro�he Worke�s'Comprnsafion lows. Li9hting Fiztorea First 20 ADDRE55
� - ' Totol No. Additional
f �;_,_„_�pplicont ��TY Tel.No.
� Fixed App�iances Not Over 1 HP PERMIT
�v.,�rCE TO APPIICANT: If, aNer making this Cerfificpte of n u
' Ezemption, you should become subject io the Workers' Range_Healer_O.W._ APPIiUNT T MeGee Eleetrie, TIlC.
� Cnmpenwtion provisiona of ihe tobor Code,you must forlh- Oven _Dryer —W.M.� ADDRE55 P�Q� $Ox 1111
� with comply with 5uch provisions or �his permit sholl be Top _FAU —W.H.—
deemed revoked.
� LICENSED CONTRACTORS DECViRATION Hoad _Fan _Ofher_ C�TY Chino 41708 7e1�N�91-6461
Disp. _Room Air Cond. _ ���N��R Class. (�''-10
i I heraby affirm tho��om licensed�nder provisiom of Ghapfer 9 REG.NUMBER 490083
� (commencing with Section 70ppJ of Division 3 of the Business power Apparotua&large Appliantes DISiRICT NO. � PROCESSED BY a
� and Professions Code,and my ticense is in full force and effecf. � U�
Size 8 Type HP,KW,KVA,or KVAR
license Number 490DR'� Lic.Class C-10
� Up ta 1 Ind. FINAL �'
` Conhotlor Electrical Dare 8/20/86 o�e�1 to 10 Ind, DATE �y��s�p� � arror� p
Over 10�0 50 Incl. FINAL W
� ❑ 1 am ezempt under Sec Over 50�0 100�nc. BY p:
Over 100 N
1 8.8P.C.for this reoson z
! pa�e, Serv�ces,Swbd.,MCC&Foneiboards �
M 0-20D Amp.llnder 60p V
� S�gnarure 201-IOOp Amp.U�der 600 V
� ❑ Over 1000 Amp.or Over 600 V �� �(,5 a
Exempiion for Reg.Moint.Elect.
� SINGIE FAM�IY Tem Powet Pole 8 A �e � • • •`�
. HOME OWNER-BUILDER DECLARATION P' PPurtenances
I hereby offirm ihot I om exempt from the Cont�actor's License Sign wilh One Brpnch Circuil I 0 +ry��2
� Law for the following reason(Section 7031.5, Business and Additional Sign Bm�ch Circuits
� Professionz Code): %_���C 2 U
� ❑ i,as owner of the properry,will do�he work and the Misc.Conduits 8 Conductors
� siructure is not infanded or offered for saie(Sec�ion Othe�(See Complete Fee Schedule�_ � 0�a 2�—8 6
I 7044,8usiness and Professions Code).
( CONSTRl1CTION LENDING AGENCY
I hereby affirm tha�there is o construction lending agency for.
i1he performance of fha work fo�which fhis permit is issued PERMIT FEE (Sub-Total)
� (Sec.3097,Civ.C.).
, PLAN CHECKING FEE
Lender's Nvme
PERMIT ISSUING FEE
Lendei s Address
I certify that 1 have read this apptimrion and state�hat�he TDTAL FEE ]3.0
a6ova information is corcetl.t ogree ro comply wirh all County
ordinances ond SMfe laws raguloting EleUriml wiring,ond
hereby outhorize representotives of fhis County io enfer upon
ihe abo�e entio�ed roperry tor inspacrion p�rposes. SfE REYfRSf EOR fxPLANATORY LAtdGUAGE
��r� �Jp�ii a/zolab
Signature of Permittee pote
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