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HomeMy WebLinkAbout1644A � WORKERS'COMPENSATtON DECLARATION 76A663 t6i81 qppllCATIO[d Ff?R �LECTRICAL PERMlT i hereby affvm-thrn Y have a cer�ificate ot consent to self._ �-�G_._ ,__ ___ .__ ... ._ .�_ -._- _ .._ .. . --- insure,or a ceriificate of Workers Compensahon Insuronce, COUDI�Y�?f LQ$/►A{G�J,E$_ BU�LD�AICs AND_SAFE'fY--- or-.a-certifiedcaPY-ther�E.{$ec.980Ek,-fe�G,;- :-- - -- .. -- --- . _" - -- _. -. _ -_ -.� .v.__ f . : .- _- .:- - :_ - -. _ _ _ _ __ �� PoOIicY.:ltlaC�77'IL€r15tTCompany� � �---�- �:- FGRdRP4tCANHfiFILF1N ` = '-=" 769`""' '. - - -- � �ertified tppy�s hereby 4urmshed,- ..� . . A}B�.J�eside�ttwt Bldg�.�'�is — EACFF• Fp. k{ .. ADDRE55 .` - ... . f t .� � _ tOCAIi _ • Certified mpy is filed with ihe wunry 6uilding insper � 7&Z-Fami{y,Sq. � _ . fion depnftmenf. . .. .. MvMi-fomify Sy.`Ft � . . . � ,. ,�••. -- NFdi&$�.. __ . . _. ... �.. ..... �.�. . _ .. . .:_ .. ... _. _ . . . -- --- CRQ53SF __, _ . .. . . - �� �� `-` - - Residential Swimming Pools _ ___ [�te � 7��7��r+ Appliwrrt T Nin!`-Pp-Rlr-�n_tr' __._ ._ _ ..._ .__ �pM�N� AY1dP1'1 �RC.. .... _.. _ - ---- - --- -- --- � ..-..CERiiFICfiTE OFfXEMPTtOM1Yf�M W�RK€RS` " .-.. OuNeis:Rec_light_Sw._ , , - ' - COMPERFSATIDN IPfSURANCE -�� - A�ORESS (Thi�c�cftoe nead E+ot ba roroplafad if thp work Mvolrat bY Ftrst 26 fhe pfrmlf te for�on�hy�ed doilan{j19G)or ks�:� -..__ Totaf No. �� _q�ktiQ��... .__ CIfY_. • _ __.. .Tel.N - _ 1. f � .._._ . . PLANCHECK � I certify tfiat Fn the perEnrmance of fhe�work for which this - � . APP1.rCANi � permR is issued;-i shaft not eTisptoy Gny person 3n any monner . -. .. . . . . .. . so os to become�subjeci 4o the Workers'��Compensati��Caws. lighting Pizt�res First 20-� ADDRE55 � � � Total No. Addifional �� _ a�A�x. -_ . . CIFY Tel.No. NOTtCE-fi0 APF4tEAf+t7:'H,�cifser�'moking lhis�ertiticate of FlxedAppl(ancesNntQvecl HP.-. PERM�7 � ��� .Exemption, you-§hbuk# becoma subjec�fo IRe-Woekers' Ronge_Heater_D.W. _ APPLICANT ,_. . .. _ . .. _ _ _.__-_._ - . Cnmpen4ntion:prov�sians�lheLa�r,Cc�de.`Yos�mus5fmif�-- Oven.:.�.DFyer=�_W�M...— � A6DR -�---- -.___ .__----- ; wiih-compiy wish such provisions or thia permit shol[ be Sop.�.__PAU-.-_W.H,�:— �� - � . --- -- --._ ..----- - �- -deemed revoked. �-�.:�. - :�;-. , . -,-� ., . � Hood�'_Fan '_Other,_._ � --:�. � �-. CIdY: • . -- Fet.N --_ � - '� - : �-LICENSED CONTRACTORSllECLARATI4N - ._. .-#Tis � Roam�AirCorkf.�� Z ,C-S.��. p-__ LICEE�SEL� _ . 4herebyaffirmikrattam4rcen5edw+derprovrsronspf�Ct+apter4 .. -` �� �� REG.hiUMBER �� . (cnmroeadrtg with Saction 700Q)of Oivi�io�3 of the B�si�ess DISFRICT N6 � PRDCESSED BY . �-and?rofessionsCode.s+�-myJicense is.#n-fuU-forceund.effe�t_....._ Po�ver Apparatus&Large Apptinnces . . . .. .. .. ._.. .�. . � . . . . .. .__._ ._.. _. ,�-- --- .__ _-.:: ___ _ . . --- Size 8 Type HP,KW,KVA,or KVAR� � f� .a � . L"rcense Number -4zQ�'4H fic CVass C-Za Up to 1 IncF. FtNAI � - � Contractor��-t . . Date � 7�22��J Qver 1 to l0lncl. � QATE��_t�-4'`j�, YALID0.TION . � - Qver id ta 50 Ind, fIN � ~ _ ❑ I am exempt under Ser. ... . .- --.. Over.50 to t4Q Inu . 6Y��� w 8.8P.C.for this reasan � Over}UO - N Services,Swbd.,MCC 8 Panel6aords . � �_ � - . � + °a1e: o-zaa amP.u�d��aao v �1 6�,4 A � _ .. .Sigrwiure - 2(11-)p06 Amp.�Under GOQ V . . . . ....- .. . - .. . � � _.. . _. . p - e:i.� s'�`� Ezemption for Reg._Mgint.Elec}. _--._._... ��1006 Am or OPer 600 V �t,• , O�5 Q _ SINGIE PAMIIY Tem Power Poke&A wtenances . -. . � MOAAE OWN€R-BUttDER DECLARATfON S�gn with One Branch Circud - •1 O��O c=i � 1 hereby Offirm ihct F_am exemgt fram.the Cnntractor's ticense Additiorml Sign�8ranch�iicuits- -� - � S� k.aw forthe faftow'rng reawn{Sectton 703F.5,9usiness and . . �Q 7.�„�� 8�j� Professions Code): � _ ❑ I,as owner of the property,wi41 do the work pnd ihe Misc.Conduits 8 ConduUors - - • structure is not interxled or offered for sate(Section 6ther(See Complete Eee SchedoleJ- � � - � - 7044,Business and Rrofessiom Codej. ` . . . _.CONSTAUCTfDN�EER1DIh(G AGENCY-._ _ _ . ... ._. _ . . . . . ; 1 hereby qffirm thql there is a construclion lendi�ng agency fw . .. ihe perfwmnnw.of the wurk for wfiich ihis permit is issued PERMR FEE - � {Sob-Tofal) � . � - . . . (Sec.309T,.Civ.C.). . . . PLAN CHEClKNG FEE_ Lender'sNome� � - � - - �� -� _ _. - � _ .._ _.___ . _.__ __. _.. .._ __. . RERbSiT-1SStJlN6-€€€—�----- . ____...__. _.__.. .__ ._._. _. _... . . . . ... . . Lender's Address ' � - - � I tenify that I.have read this_applimtion and state thal the � TOTAL FEE - above i�formation is correct.1 agree�fo tamply with o11�Cwnty . ordinances and State�laws,regulating Elecirical wiring,and ._ .�. - , � hereby aathorize representatives of ihis County to eNer upon � � � � - - tha bove-mentioned propert for inspection pu�posea � ''�f� SEE REYERSE FOR EXPLANATORYLANGUAGE . . _Signafure nf Per�ee � _..� . ..� ._ . . � __ _ . . . _ . . . . . . . . . .. _ _ _.:_ . . . . . . � _ � . � . � _ �. ._. �s ,. m v _ O O S n ��r m V��..� � � a� 0 � b a� m C CS � � � ,. � ,. �o ,�;; oo.. ; a.giyu� �i ooyavoo u� 3.o � Noai4, o�v� r o uao � nv� ,D �i �—'6 N t L �t.-�] 'b,a s . ~`.G.' � p � C u,-R`""� � �:gY,G a y d1 a� qj ' , , , - Q � �� mIIiin � b.� C�.."�.. 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