HomeMy WebLinkAbout1370 VALLEY VISTA (15) i
WORKERS'COMPENSATIONDEGLARATION 76A683 toie� APpLICA710N FOR ELECTRICAL PERMIT I
� I hereby atfirm that I have a cert'rficate of consent to self insure, CE-eo6G � i
w a certHicate of workers'compensation�nsurance,or a certitied COUNTY OF LOS ANGELES BUILDING AND SAFETV��
Policytt�r�of(Sec.3BOO.LaCoCmPa�Y-�•�•�+i�^ '�
F�l n9R �
wd� �J 7 Pdi APPLJCANT TO FlLL W ,Jp6 '�� � �
� ADDRE55
�,`Certified copy is hereby turnished. New ResidenfiaJ Bldgs.&Pools -EACtF NO. FEE
1\lc Ceriified copy is filed with� county Idi inspection 1&2•Family,Sq.Ft. "� = 3 LOCALtTY�� �� �� �
����� daParMre Multi-family Sq.FL CROSS ST.
��' �� Residential Swimmin Pools � � _ `
Date ApPli�ynt � � B OWNEFi OR
FIRMNAME ( �j�
� CERT�FtCATE OF EXEMPT F OM lNORKEH5'_ Oullets:Rec�Light�Sw.� � �`�� L� i �(��` O
CpnnPENSaTlQN I U ANCE ,: nooaess v
(This sectbn need not be c:ortip7eted'C the work invdved by ihe First 20
pertttit i&tor one hundr�d dolun(�100)a I�ae,) Total No.� Addihonal CITY Tef.N Ot
I Ceftil that in the� pe�m�� PLANCHECK'�"�" •
y perfwmance of the work tor which this aPR�M �}���1 1 � �'Iv
• �a��•��
is issued,I shall mt employ arry person in afry manner so as to ^!��`;` ' �
6ecome subject to the Workers'Compensation Laws, Lghtirg Fixtures First 20 �� ADDRESS L'f, �"
� Additional
Total No. � CITV �, �� Tel.No.
�ate �PW�eM Fixed Appliaixes Not Over 1 HP 1
NOTICE TO APPlICMtT: If, after making this Certificate of PERMIT ^-�r� '�a�R�r r.
Exemptron,you ahoukl become subject to the Nbrkera'C4mpgnsa�ion Range_ Healer_ D.W. _ nPPLICANT "1�t..A7�� d L JJ , �
provisions of the Labor Code,you must forthvrilfi comply with Such Oven_ �ryer_ W.M. A�DRESS Z��� V� ` (
.provis�a ittis permit shalt he deemed revokad. ToA — FAU _ W.H.� ���`� Tei.No. �
UCENSEO CONTRACTORS DECLARATION Hood_ Fan _ Other_ CITY
I hereby affirm that t am licensed urcier proyis�ons of Chapter 9 �� �( � LICENSE OR ^7�{ I
icommen�ting with Sectian 7000)of Division 3 of the Business and ��SP' _R6OR1 Aif COf1C. __ FEG.NUIdBEF + [ ` �� -�O
i
Professions Code,anQ my license is tn full force and effect. Power Apparatus 8 Large Appliancas D�STRICT NO. � h PROCESSLEO`6� � �
����r����/� � � � Size&TYP�.KW.I(VA.or KVAR V
;� {� �'�d ��.c�55�.�1_ �—up to i in�i. � Firu� f ��
ContraCtorC*�-'�-r...7��^�* f Daie v `^ `O Over 1 to 10 Incl. �ATE �r.�(K VAIJDATION a �
l �t/
❑ Over 10 to 50 IncL F�� � �
I am ezempt under Sec. puer 50 ro 100 Inc. By �,'�„� W 3
B P. fot this reason Over 100 a �
� ;
Services,Sw6tl.,MCC 8 Panelboards � =;�'c; ;,� .. Z 4
}e� 0-200 Amp.Under 800 V - rr�
Signature 201-7000 Amp.Under 600 V �� ° • 3 .. �
Over 1000 Amp.or Over 600 V 4 �
� Exemption r R g.Maint.Elect ( a 4 �.�
SINGLE FAMILY Tomp.Povrer Pole 8 Appurtenances r ;, ¢4 -
HOME OWNER-BUILDER�ECLARATION Sign with One&anch Circuit �� �
I h ere by a f firm i h a t I am ezemp t f ra n t h e Con tra c tor's License L aw : �,_ � -
tor the tollowing reason f�ctfon 7031.5,Business ard Rofessions Additional Sign&anch Circuits �=..� � � , -
Cotlel: !
3
❑ I,as owner pf the pmperty,will do the wark and the sVucture ���'r'O���ts 8 Corductas
is not intentled or aflered for sale�Section 7044,Business aher(See Complete Fee Schedule)_ � �
and Professions Gode�.
CANSTRUCTION LENDING AGENCV � �
I herepy affirm that Mere is a construction londing agency for the
pertormance oT the work for which this permit is issued(Sec.3097, pERMR FEE 3�
Civ.C.}. (Su6-Total)
PLAN CHECKING FEE I
Lerder's Name �
PERMR ISSUING FEE O �
Lentler's Address I
I certify that I heve read this apWication and state that tF�above TOTAL FEE ��
informatiOn is cwred.i apree fo comply with all County ordinarices - - -
antl State laws 2gulatin9 Electrical wirilg,and hereby au[Frorize
re sentatives of this to enter upon the above-mentioned
p fw i speIXp 5. � � ` „�� SEE REVERSE FOR EXPLANATOti�LANGUAGE
CL)�
'�[��l
signas �o Permittes Date
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