HomeMy WebLinkAboutNo Permit Number (4) WORKERS'COMPENSATIONDECIARATION 76A663 �o,e� qpp��CATION FOR ELECTRICAL PERMIT �
I hereby affirm�hat I have a cerfifimte of tonsent to self �E'� � �
insure,or a certificote of Workeri Compensa�ion Ins�rance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or o certified copy ihereof(Sec.3800,106.C.)
• PQolicy No.�'1 0(11121 9'Yompany T� POR APPUCANT TO Flll IN � JOB � _
Ce�lified copy is hereby furnished. New Residentiol Bldgs.8 Pools
EACH' NO. FEE AD�RE55 S RCI.
� Cerlified copy is filed wilh the county building inspec- ��g Z-Family,sq:Ff. 3n�za� s — a � iocnurr. �.�32576-4005 Diamond Ba
fion deparfinent. � ._ . . ' Multi-family Sq.Ft. — NEAREST - .
CRO55$T.
� �n ���� - Residential Swimming Pools �
Date 8�8LB3 � qpplicanf G MeGpe'E7 ectiiC �. owNes ocr
Fiam Nnnne:M.J, Brock & Sons
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlels:Rec_light_Sw._ � ���
' � COMPENSATION INSURANCE . � ' F,g�� � ADDRE55 1698.�G 2
�This section need�rot be tomplet�d if th�work Involwd by To1ol No.��4 Additional _ QTY . .BL'ea�. Tel.No529-8170 � �
fha permll ff lor ona hundred dollars(SI00)or leas.) -
I ceitii that idthe erformonce-of�the�work for which this . �NCHFCK _ � �� �
Y P APPLIfANT
permit is issued,-I shall not employ ony person in ony manner
- so as lo betome sobject to the Workers'Compensation Laws.� ��9hting Fixlores First 2(1 - ADDRE55 � � _ -
� � - ' - ' �� �� '� Toral No. 1 � Additional
- . . CITY Tel.No.
Dote - epplimnt - - � Fized Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, oftar making Ihis Certifimfe of u v
, �mplion, yoo shoold betome subject fo 1he Worken' Ronge_Heoter_D.W._ APPLICANT (J M ' .
�' pensolion provisions of the Lobor Code,yov most forth- Oven � ry ��_W.M._ -� - ADDRESS- �
_D er
I �with tomply with such provisions or ihi7 permit sholl be Top _FAU Lw.y.— - 627-0936
deemed revoked. � �� � " �"-" -- CIiY - � Tel.No
. LICENSED CONTRACTORS DECLARATION Hood _Pan _Other—
�Disp. _Room Air Cond. — . 3 $ IICENSE OR ��a� �
I hereby oHirm tha�I am licensed under provisions of Chop�er 9 REG.NUMBER �ZS337H C-10� �
(commencing with Section 7D00)of Division 3 of the Business PoN,ef A DISTRICT NO. PROC SSED BY
and Prafessions Code,and my license is in full force and eHect. PPoralus 8 Large Applianres _ � �
153378� Size 8 Type HP,KW,KVA,or KVAR- � �
LitenseNumber Lic.Cbss �C�1� " ' �Up�lol Ind. - - �� FINAL � - -- � � V �
- Over 1 to 10 Ind. DATE OC
Conrraaor� Electrical Da�e g�g�g3� � � VALIDATION
Over 10 to 50 Intl. FINAL �O
❑ I om e:empi under Sec. . Over 50 to 100 Inc. BY , q��. �� � � �w
8.&P.C.for this reason Over 100 � v6i
. . � � Sarvices,Swbd.,MCC&Paneiboards -� ► � - x
... . Date: � � 0-200 Amp.Unde�600 V _ -� -- . .. -
Signature - 201-=1000 Amp.Under 600 V -�� � �-
� - � Over 1000 Amp,or Over 6W V .
Eiemption for Reg.Moint.Elect. �
�SINGLE FAMILY . Temp.Power Pole 8 nppurtenontes � . �
HOME OWNER-BUILDER DECLARATION � Sign wiih One Bronth Circuit �
"-reby oifirm fhot I am eaempt from fhe Conhac�or's license . Additional$ign 9ranch Circuits�
)for the fallowing reason�Sedion 7031.5,Business and � - -� � -S Q G�j(1 a
I�r�oiessions Code): - � . �
❑ 1,as owner of Ihe property,will do'the wO�k pnd the Misc.Conduifs 8 Conducrors - � � � � � �i-� • •-•-•2 -
shoctore is not in�ended or ofiered for sale($etlivn Other(See Complete Fee Schedule)_ ► . . ..:I • 1 3 9.1 ,�
7044,Business and Professions Code). � � �� ��- �
CONSTRl1CTION LENDING AGENCY � . -. . . _ . _ -• • � J D.� � c=i._ �
I hereby offirm that there is a construction lending agency for
the performance of Ihe work for which this permil is issued PERMIT FEE (Sub-Total) _ _ . .__ _ .. �a� 2-��J
(Set.3097,Civ.C.). . �- .
- PLAN CHECKING FEE - � - - - - . .
Lender's Name- � � �
_. PERMIT ISSUING FEE �lO 5
lender's Address -��
I tenify that I have-read this application ond s�ote thot fhe TOTAL FEE 1 -
obove informmion is covect.I agree to comply with oll Counry � - - � � �� �
ordinances and Stole laws regulating Elecirical wiiing,and � � �
hereb a rize representmives of this Coonty to enter upon � ��- � � � - - � � � � � � �� - � �
the - en�ioned property for inspedion porposes. - - � .
� . � �--- SEE REVERSE FOR EXPLANATORY LANGl1AGE . .. . � _ . _
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