HomeMy WebLinkAbout1795A (10) WORKERS'COMPENSATIONDECIARATION � 76A669 10/Bl qpp��CATION FOR ELECTRICAL PERMIT I �� f
I hereby affirm that I hove a ceriifita�e of consenl to seli �E"� \
insure,or a certificate of Workers'Compensatian Ins�ronce, CO�JNTY-�F LO$/rNGELE$ BUILDING AND SAFETY�� �
or o certifi�ed��copy thereof(Sec.3800,Lab.C.)
Palicy Nd.J,L"=��� Company��/�i✓J/� FOR AVvIIGNT TO Hll IN JOB �+- " �
� Certified copy is hereby furnished. �N� New Residential Bldgs.8 P�p EACH NO. �E ADDRE55 a iv�m' � y.
� Certi(ied copy is filed with�he county boiiding inspec- �8 2-Family,Sq.Ft. <�( E = E �«A�� D'�oS D
NEAREST
,yoy/dep9riment. Muiri•fomily5q.FL C�tO55ST.
��i/�d� � � Residenfiol5wimming Pools OWNEROR
Date Appiicant
FIRM NAM ��
� CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec_Light__Sw._ �"�'�� '
COMPENSATION INSURANCE • aoDRE55 X ca� .
This��e�ion nNd no1 M com bbd tf Ihe work involv�d b Firsr 20
� p Y Totol No. Additional CITY �„ Tel.No �q���
-1hs p�rmif is for one hundrad dellorc(5100)or lasf.)
I certify�hal in the per{ormance of the work for which rhis APPLICANTK '
— permil is issoed,I shall not employ any person in any manner ,
so os to become sobjec��o the Workers'Compensation Laws. Lighting Fixlures First 20 ADDRESS �
� Total No. Additional CIN Tel.No.
� Dare opplimnt Fixed Appliances Not Over I HP PERmI� ii
CE TO�APPLICANT: If, after making this Cer�iiicale of ��! � ���'z���
• ,�p�ion,�you should become :u6jecf �o the Workeri Renge_Heater_D.W.` APPliG4NT
Cemp<r.satien previ�ions ef!he Lebcr Cade,you m,vst forth- Oven _Dryer _'N.Id.� AODHE55 x �/�
.wilh comply with such provisions or this�peimit shail be Top _FAII _W.H:_
�deemed revoked. � � - Hood _Fan _Other_ ' CITY �� g� Q�Tel.No. �
� LICENSED CONTRACTORS DECtARATION � uCeNSe OR
I hereby aHirm rhat I om licensed vnder p�ovisions of Chaprer 9 Disp. _Room Air Cond. _ REG.NUMBER � Class �
(commencing with Section 7(100)of Division 3 of the Buainess DISTRICT NO. PROCESSED 8Y . pr,' -
Power Apparatuz 8 targe Appliances
and Profes:ions Code,and my license is in full force and affett. �!'� �a1 O A Q V
� � Size 8 Type HP,KW,KVA,or KVAR .�" (J
licensa Nomber lia Class� - � FINA�-- �) � �
// �+� Up to 1 Incl.
�C" 7' yy Over I to IOlncl. �A�i lr��� 3-3– VALIDATION � �'
ContraUor Date o� Over 10 to SO lncl.- V
❑ FINAI W
I am exempt under Sec. � Over 50 to 100 Inc. BY O.:
�
0.8P.C.far this reason Over 100 �' z
Date: Servites,Swbd.,�MCC 8 Panelboords �
0-200 Amp.Under 600 V � �1 7 9 5 A
Signature 401•lODO Amp.Under 600 V
�O � Over 1000 Amp.or Over 600 V �i,s • e a 2
E�emption for Reg.Maint.EIecL , � • 1 1 5,8 6
SINGLE FAMIIY . Temp.Powe�Pole 8 Appurtenantes
� HOME OWNER-BUILDER DECLARATION Sign with One Branth Circvil . • e � � 5.�;ij�
I �by offirm tha�I am eaempt fram the Contractor's License Additionol Sign Bronch Circoits
Law for the following reason(Setlion 7031.5, Business and �9 2 2_E 8 � .
Professions Code): _ _ .
❑ I,as owner ot�he p�oper�y,will do the work ond the Misc.Conduits 8 Conductors
slruUwe is not iniended or offered for sale(Sedion O�her(See Comple�e Pee Schedule)_ , - �
7044,8usine¢s and Professions Code).
CONSTRUCTION LENDING AGENCY � -
I hereby affirm that there is a construction lending agency for D� _
the performance of the work for which ihis permit is issued PERMIT FEE (Su6doial) - - - � � �
(Sec.3097,Civ.C.).
� PLAN CHECKING FEE � � -
Lender's Name �j,
PERMIT ISSUING FEE /V �
lender's Address � /
�cerlify that I have reod�his applicotion ond sfo�e ihot the TOTAL FEE . � �
above information is co�rect I ogree to comply with all Counly �
ordfnonces and Sate laws regola�ing Electritol wiring,ond . . .
hereby aulhorize�epresen�otives of this CouNy lo enter upon
t ve-mentioned property for inspetiion u poses.
� �t� SEE REVERSE FOR EXPLANATORY LANGUAGE
�
ignature ci Perminee Daie
``'_ k/ ' _f. � . .._..f I � ; '- '--• , �
f. " i�. �! � ; I� i � ;�' � ' '
�.. � ir ! � i ' IL,^ ' i,, �� . .
�; - � � �/ �i . , -, r��,�i,i/ .,• . " .
_. , _ ' , ' : i�.- � �.
, �,. j . � ' r �.. � -
' � ;
�- -- - - -- -� �i. i i� � . .
; , ! i`/' _/ iz �T �'C �� ' T,.�J A C �y ''
i�. r � �/ �� ".' O �y � � �' ,R 0 Z .� , -
. I!_ ' �J� � m r . �,1 C. � d• �,p . .
' - (; t J` �' I� � �`� Z'' 2 p y , � .
; _ � I �� y� N � n "� p t� . .
! � �� ,[..� L ' O m � � . ,
� ' 0 A ''c O: �• ,� .
_ . ,� .' . � .p
� �'� � - , �"T' � ~ 7C m �V' . .
. 'o a
- � � � M - -
, � • � '� � , � � °� � ' � . �
s,
' � � _ � - - --- � � � � � �
f' / I � � ' ' ? , y �
� .
� � - � . ' '
� i• .
i - � , � '. . , . .
; i 1 ' � - � I •, ' li D� �.
,.-� . -- - � � A •
� � .- � ' �- ., : '. . �f��� �' � ..
� I ,. , . � I . ' ♦�'
' � , : �'.. � � • ' . .. ' , ; �, ' .
� ; i - ". f � , . _ � � � ..
� � � _ �� � , � ,. � �
, j . . I - .- : - �
. ' _. . . , ' '.
.
� ;
: ,
.. . , ,._ . _._. .. , ,� _._ _- --_...:. ._ . .�_; . ,:. :
. !
. . , ; ; ; � _ . •i . ; ,� �:� f ;
, p o � . [a i,a,'�� �� ' a T° m m �°� c6a° �-n j��tl'� c^ �'
; • . - - 1 . . � ? � . R' l.i�. � p-O � � 7,c-O a n �� � �-�"� �.ti + O'p� � � N m �
! , ' . ' � . • - . . , q ' b i�(5.�. � K ��`C7'n 1 C ❑N Q N O .n�� � S.+6�f0 u6i m CT
, _. . . , . . . ' . . (� '.X �CI'�0 Q�.C m �A��,^� C' , O T ,. ,�n y� •� . .
. � . . .. - _. .. , . �� �� � � O H d w C ��U Q`C C��q� C � q O �p ! , � .
-. o � � � 4 Y � W" a w a_w�o_, � m'�--�N•m,b �v 4'f � :.�
' �- � - . . � , ' . " , , .O � ` O -w0 �-N —0�--�`K�D.��� .'p K:m � . �
O
' ' . � T 'c vg '" Qv ~ n37j',•• Qm�ao,.���NBoo3 ,z :. �
I ' . '^ a ` o �a � � 3.2� ° � m� 6 o p,N � Y�-=.,� T m '
� o � -x a noN �'o . �o
� I . . : o !.�� '�°° F � n'e � 4 3 �1 � �a N o� a M��3 „ o o :C ,. -
�
_ . - - . - � ;� � �73-e a`^ a vo o - °.o- o '��`c n'a � rl° 3 v
. . - . : . .. _ . . ' ,��?.O �,O+ S O O C1'O � -� � � �''n w 7� C O � o_ m '
. � - � - ¢O _.N O b M O� O � � � ��Q C�O O _.�.. �] � A `
. .. .- . , : ' ' i �`^c.a o -..� ,�� � a m v D.n : L Y� o ...� 3 ' o
.- . " ' ' : � , ;'g � m F T� a„ o'� o �� m m l� p � o' i �� �o � .
. . , . � � � / �l p Q � � cr K ° � '
. �'�I . i . `. I- �°.�° °.m` o co o a£� �N o` °.�_�o'�«3 � ' 3 `A. •
ti � � 40� Qc �o � a� • a � �
_ � ' - , - ' a •°co 'D'F � �D °! � mo3H '3ono"o'O '�� '_p: , -..
. . . . , . _ . . , . � ; � .. f0 � � Q.�.O � `�1 Q �� t u' ', � 3 c w n C n � �Z r .. .
. . - . .. . 'O a 3 p,S W � O O G-3 7 " tC 2" G p p •_, -'
, . . .. . `�.,�` �, a m : f ?. a� � � ci> > > ,
. ., ' . ° � �-yoN.' o- ° �m �.,o�� � a°'3t'c' .,, .� . .
O ip � p,N '" O O -
1 ' . . - -. ' . '�� � S 7 � !0 b 7�- ] O n tr'O o O � �n . .,
� . � m . .� � `'-i� .. 'a� .. � � O . �S�.� .
, ' / ,. _ - �- -- , � am°'O3-� �. a` a�� MWsc�? ASsi,.N �
„,, I