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 r2 of. q�it�ee � �iY Dale � , . _ ;� , �=== � �� ' , .. . \ . . ' .' . '.. .� T.. �_�� • � . '� , � , - � . . � .. . . .�i � `' ' �� ,\\ � �,_.p .?�� p•ro � . .. , Z '^ � �.� G Z 2 A` O 9A Z � '" m G� 'n ry' � � � '� .. '. .• -. � � 7u U, - . D � p �L ' '" N O �a G O � q�n . �i 2 p • �` jc c" ,, .) v O . M � O a - y ' m _ o . } ' . c � � 0 � ' � y a , m � . �i t . . 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