HomeMy WebLinkAboutNo Permit Number (4) WORKERS'COMPENSATIONDECLARATION ��.�3 �o:e� � APPLICATION FOR ELECTRICAL� PERMIT � �
I hereby offirm ihol I hove a certificafe of consen�to S01f �"��
ins�re,or o certif�coie of Workers'Compensation Ins�rance, COUNTY OF l05 ANGELES BUILDING AND SAFETY
or a certified copy thereaf(Sec.3800,Lab.C.) . � '
P❑o�icy No�'-1 9O.�Company �TNA FON A►HICANT TO FIIL IN � �� . _ � , �-
Certified co is hereb fumished.� EACH NO. FEE A�RE`aS
pY Y New Residentiol Bldgs.8 Pools
1 8 2-Fomil s F�. 3034� S — s� �a^��TMTR�#32576-4005 Diamond Bar
O Certified topy Is filed with the coonty building Inspeo- Y� 4� . _ NEp,REST � -
tion department � - . Mulli-fomily Sq.FL� Cao55 ST. ' � �
Date�/R/R� � A licant °�'�� Mrt(]r�e-F.1 nn1-r' Residential Swimming Pools � OWNER Oq� .
pp 1C . FIRM NAM�i��T• B20C�C & SOI1S
� � CERTIFICATE OF EXEMPTION FROM WORKERS''�� Outlets:Rec_LigM_Sw._ � ' � '
°"P'�� 1698 Greenbriar Ln. #224
� � COMPENSATION INSURANCE � ADORESS'
First 20
(Thh tiMioa n�ad nof ba compl�Nd if 1h�week Inwlwd by Total No. 4 Additional � ��N .BYOd Tel.No52y_$
. �Iha parmll ia for one hundred dollen(SI00)or la�s.) .
I cerlify tFm in the parformonce�of the work for which�his . �.ANCHECK
. . . APPLIfANT ..
_ permif is issued,I shall not employ ony person in eny manner - _
so as to become subject to the Workers'Companwtion Laws. Lighting Fiztures First 20� - ADDRE55 � �
� � � � � � To�ol No. Additionol
, �, �_ CITY- Tel.No.
Date Applimnt - Fixed Applianres Not Over 1 HP
NOTICE TO APPLICANT: li, ofier makin this Certi(icate of PERrniT ,
e nwucnr,r^C" McGee Elec
. �ption, you should become subject to the Workers' . Range_Heater_D.W.—
oenwiion provisions of the Labor Code,yoo most forlh- Oven _Dryer W.M._ - � � � ADDRE5523j�.5. Reservoir �
with comply wi�h such provisions or lhis permil shall be Top _FAU �...L W.H.— �
daemed revoked. � - -� � Hood _Fan _Olher_ - - C�TM Poaana Tel.Nof2']-0936
� LICENSED CONTRACTORS DECIARATION . - 3 .SO uCFNSE OR 153378 �
I hereby offirm that�am licensed under provisions oF Chap�er 9 Disp. _Room Air Cond. — REG.NUMBER - - .� Closs.�C�ZO .
(tommenting with Sedion 7000)of Division 3 of tbe Business power Apparotus 8 Large Appliontes . DISTRICT NO. � PR SSED BY . �
�and Professions Code,ond my license is in(ull force ond effecf.
.. Size&Typa HP,KW,KVA,or KVAR � O
License Nomber 153378 Lic.Class �C-10 -. - . .. . Up to 1 Ind. . . .. . . .. FINAL . . -- . . . V
' Ove�1 to 10 Ind. �ATE / � � � yp��DAT10N �
Controctor F•�P- ri a7 Do�e 8�83 � Over 10 to SO IncL . o
❑ FINAL I_� U
I am ezempt under Sec. Over 50 to 100 Inc. BY / ��Z , �
Over 100 �
B.&P.C.for this reason . Z "
� . pa�e' � Services,Swbd.;MCC 8 Panelboards � '- -- , � � �--� -�--� � � ,
0-200 Amp.Under 500 V :'�C 9 fa'�A
Signature .. . 201-1000 Amp:Under 600 V- . . - . . . .� � .
❑ . Over 1000 Amp.or Over bOp V �� ��� �?
Exemplion for Reg.Mainf.Elec1.
I •�139.11
SINGLE FAMILY Temp.Power Pole 8 Appurtenances .
HOME OWNER-BUILDER DECLARATION Sign wilh One Branch Cirtuil • `-� 3�•� � �-
' (e6y aHirm Ihat I am exempf from the Contractor's License qddi�ionol$ign Branch Circoitz
�' J(or�he foliowing reoson(Section 7031.5, 8usiness and � O B�'� 2—g 3
YroTessions Code): � _
❑ 1,os owner of the property,will do the work ond fhe Misc.Conduits 8 Conductors-� --� �� � - � � '
strvcture is not iMended or of(ered for sale(Section Other(See Complete Fee Schedule)_ � �
7044,Business and Professions Code). � �
- - CONSTRUCiION IENDING AGENCY � �� . � � � � -
I hereby aifirm that there is a construction lending agency for � .
the performance of ihe work(or which this permit is issoed - - pERMiT FEE--� � � � � � (Su6-Total) ��-� � �� � - -� �
(Set.3097,Civ.C.).
PLAN CHECKING FEE � -� . . . . __ . . . _ ..
Lender's Name 1� 50
PERMIT ISSUING FEE . . . � . . . __ . .
Lender's Address �
I tertify ihat I have read this opplicotion and sta�e thai the TOTAI FEE . "
obove information is corred.I agree ro comply with all Covnly � . .
ordinances and Siale laws regoloting Electricol wiring,and - . - _ � �
hereb aul ori represent ' of this Coonry to enier upon � - � �. �
the v me ' property for inspec�ion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
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