HomeMy WebLinkAboutNo Permit Number (4) WORKERS'COMPENSATIONDECLARATION 76A663 �o,e� � APPLICATION FOR ELECTRICAL PERMIT �
I here6y aifirm ihat I have a cerli(itate of consenl to self �E'�
insure,or a cer�ificate o(Workers'Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified topy thereof(Sec.3800,lab.C.) �
P❑ol7cy No.C190021 23c'ompany TI1�n - FOR APPLICANT TO FllL tN . �� . ,
Cerfified[o S hereb furnished. . EACH NO. FEE A�DRESS Ipt 2], — ],$$rj �•
pY� Y New Residential Bldgs.8 Poois
�- Certified topy is filed with ihe coonty building inspeo- 1 8 2-Family,Sq.FI:'�� 21 = E - ���A�ITY�.#32576-4005 Diamond Bar
tion depariment � -�� � Molti-family Sq.Fl. GROSSSSi. - � �
Date $�8 83 n n p7et•'i-i ResideMialSwimming Pools OwNERO
I qpplicam M • c . . . . .. . FiRM Nn.M�I.J. Brock & Sons .
CERTIFICATE OF EXEMPTION FROM WORKERS' - Outlets:Rec_Lighl_Sw._ - .
-COMPENSATION INSURANCE � . - - �5 Aoo`aess �1698.Greenbriar Ln. � #224
Firsr 20
� (This t�efien nNd nof be compl�hd if fh�work involvad by Total No. � 3 Additionol QTY .BYEd Tel.No. $29-8170 � ..
!ha permlf Is For one hundnd dollan(SIQO)or bss.) PtAN CHECK � .
I cedify thot in iha performance of the work for which ihis - nvat�G4M
permit is issued,I shall not employ any person in ony monner � _
so os to become aubjed to the Workers'Compensation Laws. Li9hting Fialures Fi�sl 20 75 ADDRESS .
Additional
� Toral No. �- CITY - �- Tel.No.
Oale App�ican� � � � Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: Ii, af�er making this Certilicate of �� � APPIICANT�C�� MCC`�QQ Electric IriC
,_ lmpiion,�you shoutd become subject to the Workeri Range_Neater_D.W._ _ �
lnpensation provisions of the Lobor Code,you must forih- Oven _Dryer W.M.L ADDRE55 2390-S R
with�mmply with such provisions or this permil shall be Top —FAU .L�W.H.— ,
deemed revoked. - . - � � -" � - CIN � P � � - Tel.No. �
Hood�_Fan _Other_
� � � LICENSED CONiRACTORS OECIARATION p uCENSe OR '
I hareby affirm that I am licensad under provisions of Chapter 9 Disp.-_Room Air Cond. — � REG.NUMBER- ��.SB37S C�ass•..C-10 _
(tommencing with$ection 7000)of Division 3 of the Bvsiness - DISTRICT NO. PR SSED BY
Power Apporatus 8 Lorge Appliances Y
� ond PiaFessions Code,and my license is in full forre and eHect � - � d
. � . � � Size 8 Type HP,�KW,KVA,or KVAR� O .
License Numbar 153378 LiE.Closs C-10 Up�o I Ind. FINAL V
Conrracror E12CtY'1Cd1 � Dote 8�8/83 � � Over 1 to 10 Ind. DATE ������ VAIIDATION Q �
❑ Over 10 to 50 IncL FINAL . . . .. V
I am exempf under$ec. Over 50 fo 100 Int. BY d
Over 100 �
8.8P.C.For this reason ► , 2
� � Date: � Services,Swbd.;MCC&Panelboards � � �
0-200 Amp.Under 600 V
Signature - 201�-1000 Amp.Under 600 V- - - - . �
QOver 1000 Amp.or Over 600 V �
Exemp�ion for Reg.Maint.Elecf.
SINGIE FAMIIY - Temp.Power Pole 8 Appurtenances �
HOME OWNER-BUILDER DECIARATION Sign with One Bmnch Circuit - . � � �C ci��J 7�� .
J' reby affirm that I am ezempt from�he Contradoi s License Additional Sign Bronch Cirwits�
. }for the following reason(Section 703I.5,Bosinen and �. .�, . ,�2
Y�6fessions Code): �
❑ I,as owner of ihe properly,will do Ihe work and ihe Miic.Conduifs-8 Conductors �� � � -�-- � -." � - - •
Other See Com lete Fee Schedule ' ° 1 Q A.�O
structure is not intended or offered for sale(Section . _( P. . . �— . � .. .
7044,Business and Professlons Code). • • � ���l.5 l�u
CONSTRUCTION LENDING AGENCY � . � - � O�a� l—II 3
�hereby affirm ihat there is a consfruction lending agency for
Ihe periormance of fhe wark for which this permit is issued � PERMIT FEE � � �-�� -� - � -(Sub-Totol) - ,f34� '- - - �- - � - -- -�--�� �� � ��- �-
�Set.3097,Civ.C.). - . '
. - PLAN CHECKING FEE . .. �.. .....�. . .-. - ..... . . . . - . �
Lender's Name � � � �
. PERMIT ISSUING FEE . , . . . �ZO S . . , _ ,
lender's Address � ' 104.5
I tertify that I hove read this application and state thal Ihe . TOTAL FEE _
obove informolion is correct.I agree fo compiy with oll Co�nty
ordinonces ond Stote laws�egulating Elecfrical wiring,and -
. ._ . . _ . . . . . +
hereby uthori e representatives of this County to enter upon .
the o ov�-m �{ioned property for inspection purposes. " - �
/ - SEE REVERSE FOR EXPLANATORY LANGUAGE
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