HomeMy WebLinkAbout9567AWORKERS'COMPENSATION DECLARATION 76A663 10/81
I hereby affirm that I have a certificate of consent to self CE-806G APPLICATION FOR ELECTRICAL PERMIT
insure,or a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES 600 BUILDING AND SAFETY
or a certified copy thereof(Sec.3800,Lab.C.)
a cy No 1003782 Company STATA FUND FOR APPLICANT TO FILL IN B 1016 SUMMITRIDGE LOT 4
Certified co is hereby furnished. EACH NO. FEE ADDRESS
PY Y New Residential Bldgs.&Pools
Certified copy is filed with the county building inspec- I&2-Family,Sq.Ft. 2636 s .04 — $ 105 44 LOCALITY DIAMOND BAR TR 4 2571
tion dm nt. Multi-family Sq.Fl. NEAREST
Residential Swimming Pools
CROSS ST.
1- E & D ELECTRIC T C. g OWNER OR
Date ApplicGnt FIRM NAME XXXX M..7. BROGK & SONS,_T]
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets,Rec Light_Sw._MAIL P.O. BOX 350
COMPENSATION INSURANCE First 20
ADDRESS
This section need not be completed if the work involved by Total No. Additional CITY BREA Tel.No.529-8170
the permit is for one hundred dollars($100)or less.) PLAN CHECK
I I certify thin in the performance of the work for which this APPLICANT
permit is issued,I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS
Total No.
Additional
CITY Tel,No.
te Applicant Fixed Appliances Not Over 1 HP PERMIT
OTICE TO APPLICANT: If, after making this Certificate of APPLICANT F & D ELECTICINC.
Exemption, you should become subject to the Workers' Range_Heater—D.W.—
Compensation provisions of the Labor Code,you must forth- Oven —Dryer —W.M.— ADDRESS 319 MC ARTHUR WAY# I
with comply with such provisions or this permit shall be Top —FAU —W.H.
deemed revoked. Hood —Fan _Other_
CITY UPLAND Tel.No.946-21-31
I LICENSED CONTRACTORS DECLARATION LICENSE OR
hereby affirm that I am licensed under provisions of Chapter9 -Disp. —Room Air Cond. REG.NUMBER
f Class. C-1-
commencing with Section 7000)of Division 3 of the Business DISTRICT NO. PROCESSED BY
and Professions Code,and my license is in full force and effect. :
Power Apparatus&Large Appliances 0.
Size&Type HP,KW,KVA,or KVAR422589C-10 YP V
License Number Lic.Class Up to 1 Incl.FINALDATE me
Over 1 to lO Incl,. VALIDATION
Contractor ,E & D ELEC Date Over 10 to 50 Incl. FINAL
I am exempt under Sec. Over 50 to 100 Inc. BY
BAP.C.for this reason
Over 100
Dpte:
I.Services,Swbd.,MCC&Panelboards
I 0-200 Amp.Under 600 V
Signature 201 -1000 Amp.Under 600 V
Over 1000 Amp.or Over 600 V
Exemption for Reg.MainL Elect.
SINGLE FAMILY Temp.Power Pole&Appurte.nances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit ° F-.9 67
I 1 hereby affirm that I am exempt from the Contractor's License Additional Sign Branch CircuitsSectionnor5Bu--=
Professions Code):
n
Mist.Conduits&Conductors1 x 1 5
i El 1, Y(1I,as owner of the property,will do the work and the y
structure is not intended or offered for sale Section ;'Other(See Complete Fee Schedule)_
j 7044,Business and Professions Code). (
CONSTRUCTION LENDING AGENCY 1 U ],0 2_8 7
I hereby affirm]hat there is a construction lending agency for
the performance of the work for which this permit is issued I PERMIT FEE Sub-Total) 105 44
Sec.3097,Civ.C.).
t PLAN CHECKING FEE
Lender's Name 10 0pPERMITISSUINGFEE
Lender's Address f
1 certify that I have read this application and state that the [ TOTAL FEE 115.94
above information is correct.I agree to comply with all County t -
ordinances and State laws regulating Electrical wiring,and i
hereby authorize representatives of this County to enter upon
the above-mentioned properly for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
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