HomeMy WebLinkAboutNo Permit Number (11)WORKERS' COMPENSATION DECLARATION
1 hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance,
or a certified copy thereof (Sec. 3800, Lob. C.)
Policy No. C2277405 ,Pony INA
Certified copy is hereby furnished.
QCertified copy is filed with the county building inspec-
tion department.
Date 7/15185 Applicant" " Mrrpp_F Qr]L c
CERTIFICATE OF EXEMPTION FROM WORKERS'
( COMPENSATION INSURANCE
(This section need not be completed N the work involved by
1 the permit is for ono hundred dollars ($100) or less.)
1 certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers Compensation taws.
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be
deemed revoked.
LICENSED CONTRACTORS DECLARATION
I hereby affirm that f am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business
and Professions Code, andm license is in full force and effect.
420/48 C-10
License Number Lic. Class
Contractor Electrical Date 7/15/85
❑ I am exempt under Sec.
B.&P.C. for this reason
❑ Exemption for Reg. Maint. Elect.
SINGLE FAMILY
HOME OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License
Low for the following reason (Section 7031.5, Business and
Professions Code):
❑ 1, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued
(Sec. 3097, Civ. C.).
Lender's Name
Lenders Address
I certify that I have read this application and state that the
above information is correct. I agree to comply with all County
ordinances and State laws regulating Electrical wiring, and
hereby authorize representatives of this County to enter upon
the above-mentioned property for inspection purposes.
7/15/85
Signature of—Permittee Date
76`'663'0'61
CE -806r,
APPLICATION FOR ELECTRICAL PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFJTJ. MountainLaure
FOR APPLICANT TO FILL IN 10B
New Residential Bldgs. 8 Pools
EACH No. FEE ADDRESS Yard Litiag - S. Diamond Bar lvd.
1 8 2 -Family, Sq. Ft.
Multi -family Sq. Ft.
Residential Swimming Pools
Outlets: Rec_Light 41 Sw._
First 20
Total No.. 1 Additional
Lighting Fixtures First 20
Total No. 41 Additional
Fixed Appliances Not Over 1 HP
Range— Heater_ D.W. _
Oven —Dryer _ W.M. —
Top _ FAU — W.H. —
Hood _ Fan _ Other_
Disp. Room Air Cond. —
Power Apparatus & Large Appliances
Size 8 Type HP, KW, KVA, or KVAR
Up to 1 Incl.
.Over 1 to 10 Incl.
Over 10 to 50 Incl.
Over 50 to 100 Inc.
Over 100
Services, Swbd., MCC & Ponelboards
0 - 200 Amp. Under 600 V
201 - 1000 Amp. Under 600 V
Over 1000 Amp. or Over 600 V
Temp. Power Pole & Appurtenances
Sign with One Branch Circuit
Additional Sign Branch Circuits
Misc. Conduits & Conductors
Other (See Complete Fee Schedule)_
PERMIT FEE (Sub -Total) 51100
PLAN CHECKING FEE
PERMIT ISSUING FEE 10
TOTAL FEE cl —
SEE REVERSE FOR EXPLANATORY LANGUAGE
LOCALITY TR#34831-2 Diamond Bar
NEAREST
CROSS STOWNOR.
FIRM NAME Koppell Services
ADDRESS 3703 Long Beach Blvd
CITY Long Beach Tel. Na959-48'
ADDRESS
CITY Tel. No.
PERMIT T TIT" McGee Electric,Inc.
ADDRESS P.O. BOX 1111
CRY Chino 91708 Tel. No591-6461
-._... _. ._ ..._------ _.
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