HomeMy WebLinkAboutNo Permit Number (4) WORKERS'COMPENSATION DECLARATION �6A��,o,e� APPLICATION FOR ELECTRICAL PERMIT j� _:
I hereby affi�m thot I have a cartifico�e af cansent to self CE�806G
insure,or a certificote of Worke�s'Compensa�ion Insuranca, COUNTY�F l05 ANGELES BUILDING AND SAFETY ��
or a cert�fied copy thereof(Sec.3800,Lab.C.) - - .
P❑olicy No.C1Q0027 2$pmpany�Nj� FOR APPqCANT TO FlLL IN JOB _ .
Certified copy is hereby furnished. , . New Residential Bldgs.8 Pools
EACH. NO. FEE �+DDRESS Lpt ��
� Certified copy Is filed wirh the covnfy bailding Inspea 1 8 2-Family,Sq.FL Z132� . E — E ' LOCAIITY
� tion deparlment • � - Multi-family Sq.Ff. — NEAREST �
CRO55 ST.
Residentiol Swimmin Pools
Date�.$,(R� . Appliconf °r'�� M�Gee�83ect�ic - 9 own,ea oa . . .
� FIRM NAM�'Sy�T. Brock & Sons
� CERTIFICATE OF EXEMPTION FROM WORKERS' O�tlels:Rec_light_Sw._ N''"��
COMPENSATION INSURANCE - � ADDRE55 1698 Greenbriar LTI. #22$
First 20
. (This��Nton n�ed not be tompl�f�d if Ih�work Invelwd by To�ol No 4 � Additionol ��n' .Brea � rai.No.52g_8170 '
Ihe permN ls!or on�hundrod dollers(SI00)or lets.)� - PIAN CNECK -
I certi(y that in the performence of the work for which this� � � � qaal��qNT �� '
_ permit is issued,�sholl not employ ony person in ony manner - �
so as to become subject to�he Workers'Compensation Laws. Lighting Fixtures First 20 - ADDRESS -
�� ��� �� � �� Total No. 1 . Addirional - ' .�—
� � CIN - Tel.No. � �
Date opplicanl � - Fized Applionces Not Over 1 HP PERMiT -
NOTICE TO APPIICANT: If, aNar moking fhis Cerii{im�e of APPLICANT�� ^
��hption, you should bemme subject fo Ihe Workers' Range—Heater_D.W. �
� Jnpensotion provisions oi the Lobor Code,you most forih- Oven _Dryer W.M.L- � A�DRESS_2390 S. Reservoir�
�with comply with such provisions or �his permi� shall be Top -_FAU 1�W.H._ '
deemed revoked. Hood _Fan _o+her_ ��TM Pomona TB��N�627-0936
LICENSED CONTRACTORS DECIARATION . � 'J � LICENSE OR �
I hereby offirm thot�om licensed under provisions of Chapter 9 Disp. _Room Air Cond. _ itFG.NUMBER �IS33�JH - � --Class. �C�ZO �
(commencing with$ect�on 7000)of Division 3 of�he Business power Apparatus 8 large Applionces . DISTRICT NO. � � PR SSED 8Y� } �
ond Profes:�ons Code,and my license is in fuli(ace and effett. � d '
� _ � . Sixe 8 Type HP,KW,KVA,or KVAR- Q .
License Number 153378 i��.cioss r_�n Up to 1 Ind. FINAI V '
Electrical 8/6/83 ' o�e�1 to 101nd. DATE /E���w�� yAIIDATION �
CoNraUor Da1e � .
D Over lO to SD Ind. , �— �
FINAL
I am exempt vnder Sec. Over 5010 100 Inc. BY uVi
B.BP,C.For this reason �°ef�� - � � �
� . Servites,Swbd.,MCC 8 Panel600rds -- ► - � � � � -- - - z �
Dote: 0-2p0 Amp.Under 600 V � .
SignaNre 201•1000 Amp.Under 600 V � - � � �
❑ - . Over 1000 Amp.or Over 600 V � �
Exemp�ion for Reg.Moinl.Elect.
� SINGLE fAMiLY Tem Power Pole 8 A wtenances � � � �
. " ' HOME OWNER-6UILDER DECLARATION - P� pP �,O�1.9�I , �
[eby affirm Iho1 I am exempt from the CoMroUor's license Sign with One Branch Circait �• • •2 -
�' /for the following reason(Section 7031.5,Business and Additional Sign Bronch Circoits-�. - . . _. . . _ _ _ .. � �
Piofessions Code): � �
❑ I,as owner of the properly,will do the wark and the !`'�!sc.Conduit5&Conduttors �"- - " � � �� �-- � � . �
shucture is not infended or affered for sale(Section � O�her(See Compleie Fee Schedule)_ ► �
7044,Businass and Professions Code). . � � � �
CONSTRUQtON LENDING AGENCY- � � � . .. I � l.. o��,�,,= i
� 6 L� ir�- �:>=
I hereby affirm ihat there is a conshoction lending ogency for ,
tbe performance of the work for which Ihis permit is issoed pERMR FEE �- - - (Sub-To�al) - . � __. , .. _
(Sec.3097,Civ.C.). � . . .
� - � � PtAN CHECKING FEE� - . . •
lender's Name
� . � PERMIT ISSUING FEE - . . . �.O SO ' .
Lender's Address � . � - � �
I certify that�I have read this application and state that the TOTAI FEE � 1�6.53
obova information is mrrect.1 agree to mmply with all Couny � � - '- -
ordinonces 9nd State laws regularing Elettricol wiring,and ,
hereby aut,o ize re res tatives of lhis County to enter vpon � � � '- - � � -� '- � - � � - �
ihe o ov mne property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
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