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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 ....�-- _.._____._. ____.__.__---.--__.....-.-- -... _ . _ _ � c � � ��"� .O �,CO� ctl � � �� b �O = . . - - - � . �; y `� � p y 3 .[� � .Q _ :b G . � ' - - - . J 'VJ Q � " ��`�. .�Q, C �j � � tp .'�I � ..._ � , ' . y. 4) , .. � � N i� E � C ���^ h S �C �J 3�4� � �� . � ' . • ' y.z � �.L � n� Ee �c� ° ° U �.H �i � a � ",- .� i �'!_a`.v+.4. E m d b ro 3 . � 'C.C w .fi.. � cic' � ' . : . .- . . _ . � ; ' �C o� .u y � v �� �` � .. .sy-. �' a 'y �di v� , . ' _ ' .i . 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