HomeMy WebLinkAbout1737AWORKERS-CO`fvtA�N�A`i(�'DCSA> A
I hereby affirm that I hove,a certificate of consent to self u -
CE-806G
insure, or'o`certificate of Workers' Compensation Insurance, COUNTY O Lbs ANGELES BUILDING %IND 00Y
or a certified cloy thereof (Sec. 3800Job, C. .._,. - - -
PROM
W ,NA 56 WEST RICAN NS FOR APPLICANTTO FILL IN JOB .... .
Policy o. Company _...-.... ___., _ L,,,
Certified copy is hereby furnished. .. New Residential Bldgs &PpoL�laS
EACH NO. FEE AD0RE55" h
1 & 2-Famil 5 Ft. 10 �• — 5 0 LOCALIT T * 57034-1 LOT 8 'IQ
Certified copy is filed with the county building inspec- y q _ -
. ....' NEAREST
tion department.._
Multi-family Sq. ft. - CROSS ST KTAISIF
_ Residential Swimming Pools _ OWNER O -
Date - Applicant - - •• FIRM NAuOCALAND GROUP _
. i,Wr9'::ixA,•ti:"w: MAIL —
CERTIFICAiE' Outlets: Rec�_Light Sw AO MESS
COhSPEf•ISA710(S` IfJ$URACE First 20
(This sedion need not tie eomplMed if Tlw work imi.11"d by Total No. Additional CITIORANGE 9Z60H Tel. Norj58-9072
the permit is for *no' hundred dollars (SI00) or lass.) PIAN CHECK
I certify fhaf in the performance of the work for which this APPLICANT
permit is issued, I shall not employ any person in any m'ohn'eh' Lighting Fixtures First 20 ADDRESS _
so as to become subject to the Workers' Compensation Laws. g 9
Total No. .. CITY Tel. No..
Additional
mare ...appliconl ._ ,...... ,,...gin >�
!`1� - Fixed Appliances Not Over 1 HP PERMIT Tk -
TILE TO AP1iLZAZ1JT: If:'aft' making this CertificateofAPPLICANT VICTOR E�E�r R_I C�p�I i�C
.emptionr• you should become subject to the Workers' Range_ Heater—D.W. 2 2 SAS AV STE D
Compensation provisions of the Labor Code, you must forth- Oven _ Dryer —: W.M. — ADDRESS •
with comply with such provisions or this permit shall be Top — FAU .-_ W.H. — x
deemed revoked.,a,.s..,,sw,wm. Hood _ Fan _ Other— CITY RIVERSIDE 05�7� Tel, No]8$-9110
I herebyaffirm that I om licensed under provisions LICENSE PA _
LICENSED CONToACi'dt Dis _Room Air Cond. —
p sof Chapter 9 p" REG. NU BER 447105Clpss. -
(commencing with Section 7000) of Division 3 of the Business Power Apparatus & Large Appliances DISTRIC'1'NO._ PROCESSED BV' y,
and Professions Code, and my license is,in full force and effect. - 0
- Size & Type HP, KW, 0A, or KVAR �'G "6•f ..
License Numbe447105 tic. Class C-1 n + DATE /7 -
' ww�r.rem....,.:...•..._.•.„,w�...„. ,....,>
Over i to 110 Incl. 0
VALICATTON ... CS
Cont_roctor Ef t~f`Tl�i'C�.W.. Date .Over 10 to 50 Incl. -
FINAL / w
❑ 1 am exempt under Sec. - - Over 50 to 100 Inc. BY W
B.&P:C.. for this reason' Over 100
Dote: � Services, Swbd., MCC 8 Panelboards /
0 - 200 Amp. Under 600 V
Signature _ -- „- 201 1000 Amp. Under 600 V
❑' Over 1000 Amp. or Over 600 V 17 3.7 A
Exemption for Reg. Moint. Elect.
SINGLE FAM CY _ .... .,.. Temp. Power Pole & Appurtenances ''{ o e s n a 2
ereb affirm that I am exempt fromlth A1} ~f Y -
HON(E;OWFlEY2="B"l7TldE` ATYON
Sign with er ole6dh`Circuit ( o ®g, O
e Contractor's License. Additional Sign Branch Circuits
tow for the following reason'(Section 7031.5, Business and
Professions Code): e W n 8 9.30
❑ I, as owner of the ro er MIK. Conduits & Conductors
p p ty, will do the work and the Other (See Complete Fee Schedule)_ ® 0227-84
structure is, not intended or offered for sale (Section
7044, Business and Professions Code). -
CONSTRUCTTON LENdING`•AGEFfCY "'• -'
y' a construction
this s issued PERMIT FEE )' (Sub-To
l.1)
hereb affirm that there s g agency
the performanceof the work for, tel) 70 8-0-
(Sec.
0(Sec. 3007, Ciy: 'C. ) .................. ................. .....
_ PLAN CHECKING-FEE
Lender's Name
PERMIT ISSUING FEE"" ..: ....
Lender's Address a•-----•M---*^^�•�"
I certify that I have read this jppllcation and state that the TOTAL FEE
above information is co�-,Rp
t. I gree to comply with all County - -
ordinances and State uIati, . Electrical wiring,'and ...
hercib' -m-enterepre7a v.` r tlhi '� U�upon� SEEREVER$EFt�R-EXIFCA�XfbRY`fWd AdE f} A�Mx;¢v�wYy 9xsry `Y vr'
.of` Coun to enter
I,__ abpve-mentioned,f7 P l�c.L
Ign `re £Perm free Date”
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