HomeMy WebLinkAbout0570A WORKERS'COMPENSATION DECLARATION 76A663 �o�e� APPLICATION FOR ELECTRICAL PERMIT 3D ��
I hereby offirm that I hove a ceriifica�e of conseni to self CE-eoaG � ./
insure,o�a certifico�e oi Worke�i Compensa�ion Insurance, p��µ�,.yp F�`n��{C p��{ . B�1ILDING A1�D SAFETY Y
or o certifie th eof(Sec.3800,La6.C.) Tract ��iL767' LOi"7TJ"Y131Y L4
o�Y No. ���8g comPo„Y Wausau I I1S. FOR APPLICANT TO FILL IN �OB
Cer�ified copy is hereby furnished. New Residential Bldgs.8 Pools EACH NO. FEE �+D�RESS yj
� Certified copy is filed wiih ihe county building inspeo 1 8 2-Family,Sq.FI. ZI4R 5 — b IOCAUTYD1�T10f1C� Bc1C F"�t 115
tion deparimen�. � Multi-fami�y Sq.Ff. — NEaREST
Residentiol Swimming Pools C7t055 ST.
Do�e 7–�Applimnt��Q� Hi�] Jp('tl-1C � RMNn,°�rarrelea California inc.
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec_Light_Sw._ � ��� 3151 Ai rwa Ave. Su i te N
COMPENSAiION INSURANCE A��RESS Y
(Thfs fetfio�n�ed nof b�compl�fod 1!the work involved 6y Firs�20 CITY Costa Mesa Tel.No.
ths permif is for ene hundrad dellars(5100)or le».) Totol No. Additional � $50 1��1
I certify thof in ihe periormance o(Ihe work for which Ihis � , qppNj�ryTK –
permi�is iss�ed,I shall not employ any person in ony manner �
so as ro become subjed fo the Wo�keri Compensation lows. Li9hiing FiKturez First 20 ADDRESS �
Total No. pdditional CITY � Tel.No.
Dote App���o�� Fized App�iances Not Over 1 HP pEp,yaT
K" �E TO APPIICANT: I(, afier making rhis Certificale of A���NTGrey Hill Electric, 1nC.
E, fion, yov should become subject fo the Workers' Ronge_Heater_D.W._
Compensatian provisions of the Lobor Code,you musl fo��h- Oven _Dryer _W.M._ ADDRE55(](O–B C2nt C8I AVC.
with comply wilh such provisions or Ihis permit sholl be Top _FAU —\N.N.—
deemed�evoked. Hood —Fa� _O�her_ ��TY Ri ve rs i de rai.No.354 8900
UCENSED CONTRACTORS DECIARATION LICENSE OR
Disp. _Room Air Cond. — REG.NUM6ER 316579 C1oss.C–j�
I hereby oifirm ihot I am licensed�nder provisions of Chop�er 9 �
(commencing with Secrion 7000)of Division 3 of�he Business DISTRICT NO. � PROCESSED BY �-
and Professions Code,and my license is in full force ond effec�. Power Apporofuz&�arge Applionces y� p'
Size 8 Type HP,KW,KVA,or KVAR v U
license Number 3165�9 Lia Class �-1� Up to 1 IncL FINAI �
Grey Hi 11 Elect 7-25-86 Over 1 to IO lnd. �ATE _r �_rG VALIOATION U
Confroctor '�a�e Over 10 to 50 Incl. �
❑ FINAL � W
�am exempt under Sec. Over 50�0 100 Inc. BY d
�
8.8P.C.for this reoson Over 100 Z
D01e: Services,$wbd.,MCC 8 Ponelboards ►
0-200 Amp.Under 600 V
Signafure 201-1000 Amp.U�der 600 V �O S�I.O A
� Over I000 Amp.or Over 600 V
Exemp�ion for Reg.Maint.EIec1. �;�e s i a •2
SINGLE FAMILY Temp.Power Pole 8 Appurlenances
� HOME OWNER-BUILOER OECLARATION I �s •0�2 b
\ Sign with One 0ronch Circuil �
(^by affirm Ihat I am exempt from Ihr.Cont.ottor i Litense Addilionol Si n Branch Circ�ils a x
L�.i for the following reason(Sec��on 7031.5,Business and 9 ° �9 G 2 6 u
Professions Code�: . � -
❑ 1,as owner o}the property,will do Ihe work and the Mist.Conduifs 8 Conductors ��.� v�8 6 �.
structure is not in�ended or offered(or sale(Sec�ion Oiher(See Complete Fee Schedule)_ .
7044,Business end Professions Code). �
CONSTRUCTION LENDING AGENCY
I hereby o(firm thot fhere is o conshuclion lending agency for ,
the performance of the work for which ihis permi�is issued PERMIi FEE � (Sub•Tofal) g5 76 �
(Sec.3097,Civ.C.). .
PLAN CHECKING FEE �
Lender's Nome �
PERMIT ISSl11NG FEE . 1 O SO-
Lender's Address �
I certify that I hove read this applicoiion and s�are thot the TOTAL FEE 96.26
above informalion is mrrecf.I agree to comply wi�h oll County
ordinances and State laws regvloting Eletlriml wiring,ond � � /
hereb aufhorize rep�esenimives of this Coumy lo enter vpon �
Ihe ov -meNion d pro erty for inspection purposes.
SEE REVERSE FOR EXPLANATORY IANGUAGE ,
7-25-86
9no�ure ef Perminee Date
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