HomeMy WebLinkAbout1370 VALLEY VISTA (18) i WORKERS'COMPENSATION DECLARATION 7en663 i0ie� APPLICATION FOR ELECTR�A P R
I here6y affirm that 1 have a certiiicate of consent to self insure, ce-aosc �
or a certificate of Workers'Compensatbn Insurance,or a certified COUNTY OF LOS ANGELES BUILDING AND SP�Fr`��,! M
copy thereopf(Sec.38DO,Lab.C.� l� 4�}�A� ��
PdiGy NO.`i,7l�.v�Compgny ""�4�� FOF APPLICAN7 TO RLL iN �ppqESS-� LJ �
❑ Cartified copy is hereby fumished. New Residential 81dgs.8 Pods EACH NQ. FEE_ __ �
� Certified aapy is tiied wit he county huildi inspection 1 8 2-Femily,Sq.FL S — 8 LOCALITY ���,Q��
NEAREST
depa tmeLM�.'� / Multi-family Sq.Ft. CRoss S7. �
�ate ��~ �+ qpp�icant `' Residential Swimming Pools OWNER Oa ^�' ('�
� FlRM NAME � 1 ���-'
-�CERTIFICATE OF EXEMPTIO M NlORKERS' p (+
COMPENSATION INS E Ou[lets:Rec�Light Sw.� �� oa OHESS l { �]
(Thie section need'wt be eat�tad if 3he work involved by the First 20
permit Is Fw one hurWred dulWes!$1Q0)nr lass.� .
Total No.� pddrtionat GTY Tel.No. t�
1 Certrfy that ifl the peFformanCe d the work fOr�wh�ch thi5 pefmif PIAN CHEC � r
is issued,I shall not empby any person in any manner so as to A�t.IGw7 �r
become subjec[to the Workers'Compen5ation I.aws. Lighting Fixtwes First 20 � ADDRESS �� Ur V�
Additional �
Total No.� CI"fY �, Tef.No.
DAtC Applic9nt Fixed Appliances Not Over 1 HP PEFiMIT
NOTICE TQ APPLICANT: (f, atte� makin9 this Certificate ot ����T � �� � 7c�
Exemption,you should hecome subject fo the Nlorkers'Cornpensation Range_ Heater_ D.W. _ V �
pravisions ot the Lebor Code,you must forthwith comply with such Oven_ �ryer_ W.M. ADORES3 �3 Z �����
prwisions or this permit shall be deamed revoksd. Top _._,_ FAU _ W H.�
LICENSE�COMAAGTDRS�ECLAFiATION Hood— Fan _ Other ���Y � ���NO� � � �
I hereby aftirm that I am licensed under provisions of Chapier g uCENSE OR �
Disp..— Room Air Cond. — 1 Z'` Gass t �
(comrt�erwirig with Sec�n 7oa01 af Div�siors 3 of the Businsss ar,d HEG.NtirnaeR
Professians Gotle,antl my license is in full face ard effect. Power Apparatus&Large Appiiances aSiHtCi NO. PROCESSED Bv �
License Number�`��� Lic.Class� Size 8 Type HP.KW,KVA,or KVAfi �� � 4 �
r Up to 1 Incl. FINAL � I . U
Contracto�F 3.J��F�V.�+�'� Date � � a.O � dver 1 to 10 Incl. DATE � �`y4 YALEDATION �
�a r
❑ Over 10 ta 5�IncL FtNAL
1 am exempt under Sec. Over 50 ta 700 Inc. BY �� f W
8.&P.Q for this reason Over 100 ��^-�' ��
Services,Swbd.,MCC&PenelboarJs � z
' 0-200 Amp.Under 600 V �"
Signatura 20t-1000 Amp.Under 600 V i
❑ Ovef 1000 Amp.or OYer 600 V I
Exemption tor Maint.Elect.
- - ' SINGLE FAMILY Temp.Power Pole&Appurtenances
HOME OWNER-BUIIDER DEGLARATION Sign with One&anch Circuit �_�L� ;�, ,
1 hereby a(firm that I am exempt from the Contractor's License Law �, ,
for the following reason(SeCtion 7037.5,Business and Professions Adtlitional Sign Branch Circuits
Code): �� • • . u i �
� Misa Conduits 8 Cmxtuctors — - -� ;
I,as owner of the property,will do the wwk and the structure � �' •�4����: i
is rwt intentled or offered for sale(Section 7044,8usirress Other(See Complete Fee Schedule)_ �
and Professions Code). • •�z�� r . � �
CONSTRUCTION LENDING AGENCY � O 4.� i.—.. '
. I here6y aftirm that there is a construction lending agency for the
performance of the woric Tor which this permit is issued(Sec.3097, pERM1T FEE (Su6-Total) „2� i
Civ.C.J. (
PLAN CHECKING FEE
LerWer's Name
PERMR�SSUING FEE O
Le�er's Address ��
1 certity that I have read this application and siate that ihe above , TOTAL FEE
informatan is correct.I apree to compy with all County ordinances
and State laws regulating Electrical wiring, aM herehy authorize
eseMatires of this Counry ro enter upon the a6ove-mentioned
rtY for inspect� pases. j
/��,1�/J'` . SEE REVERSE FQfl.EXPLANATORY LANGIIAGE
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