HomeMy WebLinkAbout1233A � WORKERS'COMPENSATIONDECLARATION I�fi�0010DNf3/8) APPLICA O F R ELECTRI�AL PERMIT OL--
I hereby affirm thot I hove a cer�i(icate of mnsent lo selt ��°p.��
insore,or o certifimte of Workers'Compensation Insurance, �. COUN NG L DEPT.OP PUBLIC WORK$
or a cer�ified copy ihereoi(Sec.3000,Lab.C.J
Polity No. Company FON A T T�D FI IN JOB SJ7 ��/��G� ��
�Certified copy is hereby furnished. � ' New Residential Bldgs. o C O. FE D�RE55 Z.�
PY� Y 9 P y,y� . � . g OCALITY W
�Certified co �s filed wifh Ihe count buildin ins ec- 1 8 2-Famil 5 � T fi L N Ci�
tion depar�ment. Muhi-fomily�q.�t: �' ' � � �� , �RossssT. Lr,�,o�
Residentipl S�7Rn�m���'�Pools OWNER OR
Date App�itont FlRM NAMP'.t/iQLRlUT � .W C!
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec�Light� Sw�O ' " S �`��
COMPENSATION INSURANCE � '�', � f .4DDRE55
y,, First 20
(Th{s s«tien naed nof bo complatad if tha work involvad by 7o�al No.c.]� Additional / CITY Tel.No.
1h�p�rmit I�for ona hundred dollars(5100]or I��s.) PL4N CHECK
I certify the�in the pertormonce of ihe work for which�his APPt�CANT � 09 /Q
permi�is issued,I shail no1 employ any person in any monner
so os io become subjecl fo the Workers'Compensation Laws. � ��9hting Fixt�res First 20 ��� � ADDRE55
Addilional
Dale y����ApplicanV4�A�•s A�L.CC?�CIG Totol No.� CITY Tel.No.
NOTICE TO APPIICANT: If, after moking this Certiticate of Fixed Applionces Not Over 1 HP pERMIi �
Exemp�ion, you should become subject to the Workers' Range— Heater—D.W, — /PPIiG+TiON /8' �Q L,�CT G
Compensation provisions of the Lobor Code,you must forth- Oven —Dryer —W.M._ � ADDRE55 ,r/lOG.� ,Q///.E2
with tomply wilh such provisions o� Ihis permit sholl be Top —FAU —W.H.— �
deamed�evoked. CITY� A ' �tl TeI.No7���� �S
IiCENSED CONTRACTORS DECLARAT�ON Hood �Fan —Other�_y �,
Disp. ^ Room Air Cond./� LICENSE OR
I hereby affirm Ihat I om licensed under provisions of Chapter 9 REG.NUnneER O'C7 f Class.C�Q
(tommencing with Section 7000)of Division 3 of the Business pov,rer Apparatus 8 Large Applionces DISTRICT NO. PROCESSED 6 �
and Professions Code,and my license is in full for�e and effed. � � O
Size&Type HP,KW,KVA,or KVAR
Litense Number yy���� Lic.Class� Up to 1 Incl. FINAL V
Contratlo��ww��.J.EL.ECTIP� 7-7"tT/ Over 1 to 101nd. DATE � 1�`� �� VALIDATION �
le-- pver 1010 501nd. F-
QFINAL V
I am exempt under Sea Over 50 to 100 Inc gy W
B.SP.C.for this reason Over 100 a
► • �
� � Services,Swbd.,MCC 8 Ponelboards Z
Do1e: 0-200 Amp.Under 600 V —
Signafure 201-1000 Amp.Under 600 V
� Exemp�ion for Reg.Maint.Elect. Over 1000 Amp.or Over 600 v ' L•� 2�3 A
SINGLE FAMILY Temp.Power Pole 8 Appurtenances �'� �' �y 2
HOME OWNER-BU�LDER DECIARATION �
1 hereby afiirm that 1 am e.empt from the Con�rocror's license Sign wilh One Bronch Cirtuil '�!y 7 a Jr O
Law for the following reason(Section 7031.5,Business ond �+ddirional Sign 6ronch Circuirs
Professions Code): y••�•7(j Jr Q c=i
❑I,as owner of ihe property,will do fhe work and ihe Misc.Conduits 8 Conduclors ��'�7`8 9
structure is not inlended or offered for sale(Section 7044, Orher(See Complete Fee Schedule� , •
B�s�ness and Professions Code). �
CONSTRUCTION LEN�ING AGENCY .
I hereby offirm thot there is a consrruction lending agenty for
1he performance ot the work for whith this permit is issued PERMIT FEE (Sub-Tolal� G Q
(Sec.3097,Civ.C.). '
PLAN CHECKING FEE
lendei s Name �
PERMIT ISSUING FEE r D
Lender's Address
I certify Ihat I have reod this opplicotion pnd store that the TOTAL FEE O�
above informa�ion is torrect.I ag�ee�a tomply wiih all County .
ordinantes and State lows regulating Eleclrical wiring,and '
here6y au�horize represeniotives of ihis County to enter upon �
ihe above-mentioned property tor inspettion purposes. � SEE REVERSE FOR E%PLANATORY LANGUAGE
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Signature of Permitiee Daie � �'
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