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HomeMy WebLinkAbout6073AWORKERS! COMPENSATION DECLARATION 76A663 GE 606G (2-801__ ,R,,'}, .. AQFLJ TI N FOR,.ELE.CTRI.CAL PERMIT. I hereby affutn-that ,I have a ce{(tfjwcate _91 -cm e to self , ,mom , ,r_ , (a, [,O f1f 1Pi,L S.. , ,.: .,._ .. BU.ILOING AIV17 :rAF'l:TYinsure, or a certificate of Workers' Compensation Insurance, or a certified copy thereof (Sec. 3800, Lab. C.) FOR APPLICANT TO FILL IN SOB EACHNewResidentialBldgs. &Pools ® ,V' a g_ v _ Policy No. Company NO. FEE ADDRESS T,7 ea tr. •W,1r,, KAA I\G Certified copy is hereby furnished. 1 & 2 -Family, Sq. Ft. S S LOCALITY F]Certified copy is filed with the county building inspection Multi -family Sq. Ft. CROSS ST -7k 0 1 l P department. Residential 5evirl'n7ri fg'P801r' cj-q' OWNER OR Ana_",ra y FIRM NAME Vcx/vVr.'v Date Applicant CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE This section need not be completed if the work involved by the permit is for one hundred dollars (S100) or less.) 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws. Date-3_ rpubp pplicant )w \V%]QTVQAJi NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- with comply with such provisions or this permit shall be deemed revoked. LICEKST-D CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Busi- ness and Professions Code, and my license is in full force and effect. ""'' q r ^ t',. License Numb- (r Z -yLic. rClas- 0 ,-`+n ContractA t ltl_ _ atroS' q _0"— HOME OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Busi. ness and Professions Code): 1, as owner of the property, will do the work and the structure. is, not intended or offered for sale (Section 7044, Business And.Professions Code). CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. Civ. C.A- .„..___ Lender's Nameme 1"" _ Lender's Address Outlets: Rec.—Light _ Sev MAIL First 20 ADDRESS tri Total No. Additional CITY Tel No 6q4 0741 PLAN CHECK APPLICANT rLO Lighting Fixtures First 20 ADDRESS Total No, Additional G'C Fixed Appliances Not Over 1 HP CITY Tel No. Range_ Heater_ D.W. PERMIT APPLICANT 0 - Oven _ Dryer _ W.M. _ ADDRESS Top _ FAU _ W.H. _ o Hood T Fan _Other_ y . CITY L•, Tel Nol Disp. -Roo AirCori LICENSE OR REG. NUMBER Class Power Apparatus & Large Appliances DISTRICT NO. PROCESSED BY Size & Type HP, KW, KVA, or KVAR Up to 1 Incl. Over 1 to 10 Incl. FINALDATE fir- Over 10 to 50 Incl. VALIDATION Over 50 to 100 Inc. FINAL Over 100 BY Services 0-200 Amp. Under 600 V a 201-1000 Amp. Under 600 V s .,, •d ;+ v Over 1000 Amp. or Over 600 V 5 .y 4'2 px Temp. Power Pole & Appurtenances Signwith One Branch Circuit Additional Sign Branch Circuits Misc. Conduits & Conductors Other (See Complete Fee Schedulel— PERMIT FEE ISub-Total) PLAN CHECKING FEE (One -Fourth Permit Fee) PERMIT ISSUING FEE I certify that L.have read this application and state that the TOTAL FEE above information is correct. 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