HomeMy WebLinkAboutNo Permit Number (4) WORKER$'COMPENSATIONDECIARATION - 76A663 �0/si APPUCATION FOR ELECTRICAL PERMIT � j� ;
I hereby offirm that I have o certifitate of consent to self� CE-8o6G
tnsure,or a ce.tifcote of Workers'Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAPETY L�
or a tei�ified copy thereof(Sec.380D,lob.C.) • .. �
P❑oilcy No.CI9��Z123CompanyiHA FOR APPIICANT TO FILL IN - JOB _ �
CertiFied copy is hereby furnished. New Residenlial Bidgs.8 Pools� EACH NO. FEE A��E� RC�{.
�� Cartified copy is filed wi�h the tounty bvilding Inspec- 1 8 2-Family,Sq.Ft. �9l-'29� � E = S LOCALITYTR. ZS - ,
lion deporiment, �. . . Molti-fomily Sq:Ft. NEAREST , .
Residenlial5wimmin Pools CROSSST.
Date�R/��Applicont�n�'^ MnC',r+a'Rloni�riC � g OWNEROR �
FIRM NAM�S.J• BIOC�C & SOIIS
CERTIFICATE OF EXEMPTION FROM WORKERS � pullels:Rac__light__Sw._ � • �'�'��
� COMPENSATION INSURANCE � � ADDRE55 �1E9$ GI2E[1bP1aY LTI. � #224 �
First 20 52 -8170
(Thi�f�cfien novd not bo complat�d if 1hs werk inrolr�d 6y To1al No. � - Addirionol CIN . _ Tel.No
�h�permit Is ier one hundr�d dollars(5100)or lett.) PtAN CHECK �
I certify thoi in the performance of ihe work for which this -� qpPliC4NT �"� - ��� � '
permil is issaed,I sholl not employ any person in any manner � , _
so as to become subject ro the Wo�ked Compensation Laws. Li9h�ing FixWres Firsf 20 ADDRESS � - - -
' � � � - � �- �Total No. � Additionol CITY� - � Tal.No. �
pote epplimnl � � Ftxed Appliances Not Over 1 HP � . f�ERM�T .
NOTICE TO APPLICANT: If, of�er moking this Certiflca�e of � � AaPLiC4NT° ^
� rmption, you should bacome wbject to the Workeri Range_Healer_D.W._ � ,
Jnpensalion provisions of�he tabor Code,you.must fonh- Oven _Dryer W.M.,.. ADDRE55$390;S. Reservoir
�with-compiy with soch provisions or this permit shall be Top _FAU� L W.H.— ��n, pomona . . 7e1.nio627-0936
deemed revoked.�� � � Hood _Fon _Other_
LICENSED CONTRACTORS�ECLARATION � .j] 0 uCENSE O�v �
I hereby aHirm thof I am licensed under provisions of Chapter 9 Disp. _Room Air Cond. — �.SB3�]$ Cloas. �(]-].� . .
REG.NUMaLR�
(commencing wi�h Seclion 7000)of Division 3 of the 8usiness power Apparaius&Large Appliances DISTRICT NO. � PR SSED BY � '
� and Professions Code,and my license is in full force and effect. �� � `-- p,
153378 Size 8 Type HP,KW,KVA,or KVAR �
License Number lic.Class �C�10 ���� - . Up to�l Ind. � - � - - F�NA� �" � - V
- Over 1 fo 10 Ind. DATE //�3� p� yAIIDATiON �
com�a��or Electrical pa�e $l8�8^3 � �
Over 10 to 50 IncL . FINAL ~
❑ I om eaemp�under Sec Over 50�o I00 Ino BY l � � �
8.8P.C.for Ihis reason Over 100 _ � � �n
. �. . . - � Services,Swbd.,MCC 8 Panel6oards ► � - . -�-- �- � - Z
Date: 0-200 Amp.Under 600 V
Signature -"201-1000 Amp.Under 600 V ' -� �� � - ' � � -
❑ Over 1000 Amp.or Over 600 V , ,
Exemp�ion for Reg.Main4 Elect.
SINGLE FAMILY . Temp.Power Pole&Appvrtenonces �
HOME OWNER-BUIIDER DECLARATION Sign with One Branch Circuil �
"� reby offirm thol I om exempt from 1he Controdor's litense . Additionol Sign Branch Circuits � . .. _ _ �:0.9�.� �'�
}for the following reason�Section 7031.5, Business and -
�r�tifessions Code): .
� � '- Mist.-ConduitsBConductors �- � � � �� - - -'- � �� �`� ' �-2 - . _
I,as owner of the property,will da the work and the Other(See Compiete Fee Schedule)_
strocture is nol intended or oHered for sale(Section . ... ► . . _ .. � � •.��� �E:�J � �
704E,Business and Professions Code�. ,
CONSTRUCTION LENDING AGENCY � - � - ����� ���'���
I herPeb ofiirm thaf�here is a mnslruction len�in o enc for �RMIT �a I 2�-�J
Y 9 9 Y
the erformonce of the work far which thiz ermit is issued - FEE � � � - � � (Sob-Total) � ,96 .- . -� � .. � _. . _ . . . _..
- (Sec.3097.Civ.C.). : - .
PLAN CHECKING FEE � � - .. . _,._ , , . , .
� Lender's Name ' �
-: PERMIT ISSUING FEE . � �10 50 � ,
Lender's Address ' � � ��
I certify that I hove read fhis oppiitation and stote thot the TOTAL fEE - ],Q(.S$ . . _
above information Is correct.I agree�o tompiy with oll County �
ordin c s and Staie laws regolating Electrical wiring,ond '
her ' orire repres latives oi Ihis Couo�y�o enter upon . � ' � � � ' � ��- � � --
fh - enf' properry for inspec�ion purposes. -�
-- � SEE REVERSE FOR EXPLANATORY LANGUAGE
G� 8/8/83
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