HomeMy WebLinkAbout0576A (4)WORKERS' COMPENSATION DECLARATION
I hereby offlrm that I have a certifico-e of consent to self
insure, or a cerldicalr,. of Workers' Compensaticn Insurance,
or n certified cop hereof (Sec. 3800, Lob. C.)
Policy No. p campany rausau In.
Certified copy is hereby furnished.
Certified copy is filed with the county building inspec-
lion department.
Do,a7-25-86 Applicnn,Grey Hill Electric,
CERTIFICATE OF EXVIPTION FROM WORKERS'
COMPENSATION INSURANCE
This section need not be completed If the work Involved by
the permit Is for one hundred dollars ($.100) or less.)
I comfy that In the performance of the work for which this
permit is issued, I shell not employ any person in any manner
so as to become subject to the Workers' Compensation Laws.
Date, Applicant
N' E TO APPLICANT: If, after making this Certificate of
E, ,tion, you should become subject to the Workers'
Camnensntinn previsions of the Lnho• Ccde, you must farth-
w0h comply with such provisions or this permit shall be
deemed revoked.
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9
commencing with Section 7000) of Division 3 of the Business
and Professions Code., and my license. is in full force and effect.
License Number 1116579 Lic, Class ('.– 10
Contractor Grey Hill Electoe,e 7-25-86
1 am e.empt under Sec.
B.BP.C. for this reason
Date:
E.emplion for Reg. Mcrint. Elect.
SINGLE FAMILY
HOME OWNER -BUILDER DECLARATION
1 I)y arfirm !hot I am e..empl from the Contractor's License.
Law .or the following reason (Section 7031.5, Business and
Professions Code):
I, as owner of the properly, will do the work and the
structure is not intended or offered for sale (Section
7044, Business and Professions Code).
CONSTRUCTION I ENDING AGENCY
I hereby affirmlhot there is a cons!ruction lending agency for
the performance of the work for which this permit is issued
Sec. 3097, Civ. C.).
Lender's Name
Lender's Address.
I certify that I hove read this applica'ion and state. that the
above, information is ca•recl. I agree to comply with all County
ordinances and Sta•e laws regulating Electrical wiring, and
hereby authorize representatives of this County to enter upon
the ove-mennor d prop 0 forinspectionpurposes.
f' oture e`Permntee / Dote.
s"""'°'B'
E -806G APPLICATION FOR ELECTRICAL PERMIT
CCppUU q Tract r742565 Lot A P1anLES3
BUILDING AND SAFETY
FOR APPLICANT TO FILL IN
2
JOB
New Residential Bldgs. R Pools EACHNO. FEE ADDRE24409 E. Penrose Ct.
1 R 2-Fomily, Sq. Ft. 18.84 s I—Is 75 118 LOCALITYDiawnd
Mulli-family Sq. Ft. I — I I NEAREST
Residential Swimming Pools
CR0555T.
owNER oR
Outlets: Rec_Light_Sw._
First 20
Toto[ No. Additional
Lighting Fixtures First 20
Total No.
Additional
Fised Appliances Not Over I HP
Range_ Healer_D.W.
Oven _ Dryer _ r.,.
Top _ FAU _ W.H. —
Hood _ Fan _ Other_
Disp. _ Room Air Cond. —
Power Apparatus R Large Appliances
Size R Type HP, KW, KVA, or KVAR
Up to 1 Incl.
Over I to 10 Incl.
Over 10 to 50 Incl.
Over 50 to 100 Inc.
Over 100
Services, Swbd., MCC R Ponelboards
0 - 200 Amp. Under 600 V
201 - 1000 Amp. Under 600 V
Over 1000 Amp. or Over 600 V
Temp. Power Pole R Appurtenances
Sign with Ore Branch Circuit
Addtuonol Sirn Branch Circuits
Misc. Conduits R Conductors
Other (See Complete Fee Schedule)_
FIRrt NAFAF Bramalea California, If
MAILADDRESS 3151 Aimay Ave. Sute LN
CITY r -n f- M. . . Tel. No. Rin
ADDRESS
CITY
I
I CITY Tel. No.
PERMIT FEE (Sub -Total) 751381
PLAN CHECKING FEE
PERMIT ISSUING FEE I O 50
TOTAL FEE
SEE REVERSE FOR EXPLANATORY LANGUAGE
ADDRESS 6760-B Central Ave.
CITY Riverside TeI.No. 3548900
i`c^NSEoe 16579 closs.-10
d
FINALDATE
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