HomeMy WebLinkAboutNo Permit Number WORKERS'COMPENSATIONOECIARATION ��� ,�;a� APPLICAT{ON FOR ELECTRICAL PERMIT �
I hereby affirm that I have a certi(icate of consent to self . CE-806G
insure,or a certifica�e of Workers'Compensation Insuronce, � COUNTY OF LO$ANGELES BUIl01NG AND SAFETY
or a certified mpy thereof(Se[.3800,La6.C.) � �
PDoilcy No.�'7 q00?l 7ir-ampany �jg FOR AiPLICANT i0 FILL IN JOB _ . .
Cerfified copy is hereby furnished. New Residential Bldgs.8 Pools EACH NO. FEE ADDRESS jpt: `Z ��
� 1 8 2-Famil 5 ft. � 21��?� � a — E LOCALITY - .
Certified copy is filed wirh the county b�ilding inspec- Y� 9•
fiOn depoftmenf. - - � ' MVlli-fomily$q.Ft. — NEAREST .
Residenlial Swimming Poals CROSS ST.
Dafe�/�IR� APPlitan���'�� Mn(_aa'F7 nnFri n . OWNER OR ,M�J .
� FIRM NAME . Brock & Sons
� CERTIFICA7E OF EXEMPTION FROM WORKERS'��' 0�11e1s:Rec_light_Sw._ ' - � DDRE55 1698,Greenbri
� � COMPENSATION INSURANCE ' �-�
This s�c}ion nNd not 6s eom INad tf thb�work Invoivad b - Firs�20
� p Y Total No.�_ Addirio�al - ��TY Brea � rei.No529-8170�
th�pnmlt I�lor on�hundrad dollan(5100)or'leas.) .
I certify fho�in the periormance of ihe work-for whitN this . . -� � - q�N�NjK �
,permil is issued,1 shall not employ any person in ony manner -
- . so as to become sobjecl 10 Ihe Workeri Compensation Laws. LigMing Fixtores Firsf 20 AODRE55� � � � �
� - � � � Toral No.� 1 Addifional CITY � � � � .
Tel.No.
Dote�Appiicanl � � ' Fixed Appliances Not Over I HP pEpMiT
NOTICE TO APPLICANT; If, aiter moking this Certiiicate of � n q
}mption, you shouid become sob�ect to the Workan' Range_Hea�er_D.W.� � APPLICANT C MC
,�npensalion provisions of the tobor Code,you mvst forth- � Oven _Dryer W.M._ ADDRE55 2390.
viiih comply with such p�ovisions or�Ihis permii shall be _Top, —FAU �_L W.H.— � •
deemad re�okad. Hood _Fo� _oihe�_ cilr Pomona rai.rio627-0936
� LICENSED CONTRACTORS DECLARATION � � � O UCeNse O�t '
I hereby affitm ihat I am licensad under provisions of Chapter9 Disp. _Room Air Cond. — REG.NVM9ER 153378 . Ciou.C-10�� �
(tommencing with$ecfion 7000)of Division 3 of fhe Business � DISTRICT NO. PROC D BY� •
ond Professions Code,and my license is in full force and eHecL Power Apporofus 8 lorge Applionces .q }� �
- . , - Size 8 Type HP,KW,KVA,or KVAR� ' � �1 �
� License Num6er i 53378 Lic,Class '� - � - - FINAL � � ����� � - � - V
���.g Up to 1 IncL �
� Contro[tor Electrical Date 8�8I83 � Over 1 to IO ind. �A�ja- - �� YAL�DATION �
Over 10 to 50 Ind. FINAL ~
.❑ I am exempf under Sec . .Over.50 fo 100 Int. 8Y 6 -
' B.BP.C.for this reason �� Over 100 ' w
.. - _ . - Servites.-Swbd.,MCC 8 Panelboards. . . . ►. . . ..-. � . . ... 2
Date: 0-200 Amp.Under 600 V �
�Signa�ure '�201�-1000 Amp:Under 600 V � � � �- -�- - - � - �
❑ � . . Over 1000 Amp.or Over 6W V � . .. . . . . . :
Exemption for Reg.MainL E ett.
_ .._... . .. ._ .
� � SINGLE FAMILY Temp.Power Pole 8 Appurtenances �
HOME OWNEB•BUILDER DECLARA710N Sign wilh One Branth Circvit � �V�
' reby offirm lhat I am ezempt from ihe Contracror's License ��9
� �for ihe following reason(Section 7031.5,Business and Additional Sign Branch Circuits � � . -... .. �,•,•�..: .2
F�Ofessions Code}: . � .
� � �Miic.Conduits�8 Conductbrs�� �� - - � - � �-
I,os owner of fhe property,will do�he work and fhe �'•'1 O�Q 5�3
siructure is noi intended or offered for soie(Sedion Oiher(See Complete Fee Schedule)_ �
7044,8usiness and Professions Code). •�e � O h 5 J�
. CONSTRUCTION LENDING AGENCY - - - - � �-� - ��-��
I hereby aHirm fhat there is a consfrutlion lending ogenty for ��+� C-�II J���
Ihe perfo�monce of Ihe work for which ihis pe�mif is issued PERMIT iEE �� -- � (Sub-Tolal) .j6 03 � - " � - . . -._ .
(Sec.3097,Civ.C.). - � � .
- PLAN CHECKING FEE � � - -- - . . . . . . . ___ . .
Lender's Name � � � .
PERMIT ISSUING FEE _. ZO SO � . �
Lendar's Address � � � �- � � �
I certify ihot I hove read this opplication ond sta�e�hat the TOTAL FEE � jQ6.$3 . . . . �
above informalion is mrrect.I agree to comply with all Coonry , � - � -
ordinantes and$tafe laws regolafing Elecliicol wiiing,ond . �
hereby auth 'ze representotives of this County ro enler upon - -� , -- � � � � - - � � � � � -
the eb e- one arty for inspecfion purposes. _
- SEE REVERSE FOR EXPLANATORY LANGUAGE
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