HomeMy WebLinkAbout1647A WORKERS'COMPENSATION DECLARATION ��� ���ei APPLICATION �OR ELECTRIGAL PERMIT _1
I hereby affirm thm I hove a certificate of consent to self ��� � � �
Insure,er a.certificate nf Wockers Compensariort lnsurartce, C OUN T Y O F I O S A N G E C E S S U I L D I f V L�[��p�F E T Y � �
or�tif_ie�,d�copy t�¢�o}(Se£...3800,lab.C.) � -�77 �
2SSV ia! Q�' f _•., } � �l
P�ol�cy No./ , Compan �5.���� FON APPLICANT TO FNL IN � ADDRE55 -c, � �
Ceriified copy is heraby furnished. Y
,� Certified copy is filed witb�he county building inspec- N MvlRi�fam lY 1�81F�s. Po_,ik p�,., 5��H ' NO. §.......PEE. .... .......-_. . ....... .. . .. .... �
�� . LOCALIT_Y .� . 0.,.
iJEARESi� , .. . ,i
tion department --- .- -.. --.-..-- Y 59� - F�2p55 5T. .....-...
..._.... .. . _.. __... ... . �
_.. .....
� � a_ Residenlial Swimming Pools OWNER OR
Do�e� Applicant � FIRMNAME Q-�-�-
CERTIFICATE OF E%EM7TION FROM WORKERS' � Ovllets:Rec_light_Sw._ ��� �sU
LOMPENSATION{NSt1RANCE �� ��� - a�oREss/O 7 .
iirst 20
(This sxi7on ot�d�wt ba complalod tf/ha wo�ic inrdawd hr �Totnf No. Addi�ionol QTY��. �Tel.No.g6 -
th�parmi!is for ona huwdrad dollara�tt W)w{os�.) ptqN CHEUc
I cenify that in fhe performance of ihe work for which this . -APP[10WT-�--� � �
permit is issued,i shall not employ any person in any manner
ao 0o ro become su6jecl to rbe Wor4era'.Compensalion laws. U9hling Fintvres First 20 ADDRE55
... . ._..�.. ....._ . ... .....� . . . Addirionof -. . ... ...
� '�" Tolal No. . CITY . . - iel.No.
�,j. �ate �TP������ -� - Fixed Appliances Nol Over 1 HP
� �� 'TICE TO APPIICANT: If, after making this Certifiwte of PERMIi
Ran e_Heoter_D.W.— APPL�CAN7
.nption, you should become subjecf fo Iha WorLers' fl
� Lompensation provisions of rhe labor Code,ypu must forth- Oven _Dryer —W.M.— ADORE55- �
.. with tomply with avch provisions or.lbis perroit shnlf be Top _FAU —W�H.— � - �
. deemed rwokad. . . .. . ... ... - � . . . Hood �. . _ . . .. ... C�N -...-- '( )C . Tal.No. � ,
LICENSED CONTRACTORS DECIARATION -� —Faa O�her_
Dis _Room Air Cond. — �����R �- Cfoss. . -
�. I hereby uliirm thot 1 om 4icensed unde.prmisiwrs�of�Ehapter 9 P- � REG.NUMBER �
{wmmencing with Section 7000)of�ivisio�3 of fhe Busi�ess power Apparatus&large Applionces DISTRICf� PROCESS � O ;
ond Professions Code,pnd my license is in 4ull force and effect. d
Size 8 Type HP,KW,KVk,o.KVAR �
v
license Number� I � tic.Class ��a , Up to 7 Ind. p�'L � tls ��� .� � �. �: -!^. O
Over I to 10 Ind. � YAUd_�AYIOH
Contmcto � ��B �V`� Over 10 to 50 Ind. : c s .
FINAL .. ° c W
❑ I am exempt under Sec. Over 50 to 100 Int. BY �(��, ')� , ?r,;., y
Ovar 700 �'y�V .I-�+ i l, , . ._
B.BP.C.for this reasan � Z
. Services,Swbd.,MCL 8 Ponelboords � - -
Date: 0-Z00 AmP.U�der 600 V • a � _ . :,`i.-
SignaWre . 2bt-1000 Amp.Under 600 V � .��_.:;._c.r;.
❑ Over 1000 Amp.or Ove�600 V
Exemprion for Reg.Maint.Eled.
SINGLE FAMILY Temp.Power Pole 8 Appurtenonces I
� HOME OWNER-BUILDER DECLARATION Sign wieh One Branch Circuit f
eby af4irm that 1 am exempt from the Coniractor's license Additionot Sign Branch Grcuifs
.�far the following reoson(Section 7031.5, Business and i
Prafessians Code):
� Misc.Conduits 8 Conducrors �
I,as owner of the property,will do the work ond tha p�her See Com leie Fee Schedule
structure is no�intended or offered for sale(Section � P �— �
704d,Business and Professions Code).
CONSTRUCTION LEN�ING AGENCY - I
I hereby affirm fho�fiere ia a mnstruciion lending agency for �
� the performance of�he work for which fhis permit is issued PERMIT FEE � - (Sub-Total� 9 ��
(Sec.3097,Civ.C.). �
PLAN CHECKING FEE �
lender's Name �
PERM�T iSSUING FEE U
Lender's Address n '
I certify thut I have read this applica�ion and slate that the TOTAI fEE �0 �� V j
above informa�ion is correct.t ogree to comply with a{�CouNy � �
ordinances and Sio�e taws reguloting Eledrical wiring,and �
hereby aulhorize representotives of this County fo enter upon
rhe a6ove-me�tioned roperry for inspection purposes SEE RfVERSE FOR E%PLANATORY IANGUAGE
�no�ure of Permittee <� D�� �
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