HomeMy WebLinkAbout1370 VALLEY VISTA (49) WORKERS'COMPENSATION�ECLARATION 7aA6a3 to/9i APPLICATIOfV FOR ELECTRICAL PERMIT S�G f� �
1 hereby affirm that I have a cerCrficate of consent to seif insure, CE-soaci �
or a ce ate of wakers'Compensatbn�n ur nce,�or e,certitied COUNTY OF LOS ANGELES BUIL�ING AND SAFETY�.
C.) �C!
i . ^ �,p� ' � FOR APPLICANT TO FIIL IN pppRE55
� Certified copy is hereby furnished. New Residential 81tlgs.&Pools EACN NO. FEE �
��Certi�ied copy is Eiled with the nty �kting Ins ection 1&2-Family,Sq.FL � — $ LOCALfTY
. depyr[msnt Multi-family 5q.PL — NEAREST �
�� i �APPlican Residential Swimming Pools OWN R OR n ✓ �.
��� FiRM W1ME t � ��
CER71fICATE OF EXEMPTION FR �Ryi � � �� � kwL �
� QAlets:Rec LigM— w.—
- ��� GOMP€NSATlON INSURA GE - � ( Q MOFiESS
�This sacdon naed not be completed'rf the work inv ed by the ry First 20
permit Is for wie twntlred doilars($700)or lese.4
Total No.��`j qdditional CITY �� Tel.No.�-1
I certity that in the performarice of the wark fof which this permit P �
aaaucaNr
�issued,i shail not empby any person in any manrier so as to q �
become subject to the V�Urlrers'-Compensation Laws. Lighiing Fixtures First 20 ��% ADDRESS �� �
Additional
pate Apdicant Total No.� CITY .No.
t!' ':E TO APPUCANT: N, after makir�g this CortiEicato of Fixed Appliances Not Over 1 NP pEa ii _
� P��.Y�840u1d b9CAri1e suhleCt t�ttla Wp[ke[s Go6lPensation Range_ Heater_QW. AF'PLICAN _ �
provisions of ihe Labor Code,you must forthwBh comply wi[h such Oven _ Dryer_ W.M.� A�ORE �
provisiore or this permit shall he deemed rewked. 7op _ FAU _ W.H._ I e
LICENSEP CpNTRAG70R5 OECLARATION Hood_ Fan — Other— CITY , �4� f
1 hereby attirm thet�am licensed under provi8ion� Of.Chaptcr 9 LJC SEOR � � �
�isp. — ROom AiF Cand. _ REG.kl1MBE
(commencing with Section 7000)of Divisicmr 9 of the Busirress arM �
Professions Code,and my Vicerese is in full force and effect. pp��Apparatus&Larye Appliances �ISTRiG7 NO. PaqCES5E0 ev
/y �/� Size&Type HP,KW,KVA,or KVAR Q
(� � �
License Num ic.Class_(,,....[_L1— Up to 1 lncl. FINAL ' � v 3
C.aniraCt te� . Over t to 10 InG. � DATE a-/�� .VALIDATION Q �
� Over 10 W SO lncl. FINAL �
1 am exempt u er Sea Over 50 to 100 Inc. gy W
6.&P.C,tor this reason �-� Over 100 �'
� Services,Swbd.,MCC&Parxd6oards � z
6-200 Amp.Under 600 V -
Signature ,� 2�1-1000 Amp.Under 600 V
❑�� --- / Over 100�Amp.w Over 600 V `
Exemption or Reg.MaiqY.Elect. I
__ __- _ . . .. --. -"SINGLE FAM�CY'_.."'_'.._.. .. -�. . Temp.Power Pofe 8 APPurtenances _-:. � :. �
HOME OWNER-BUILOEF oECLARATiON Sign wRh One Branch Gircud
� �by affirm that I am exempt from the Cor�tractor's License law � _ �
i,. .ne toilowing reason(Section 7031.5,Business ar�d Protessions ����g�&ar�h Cifcuits r -- - - - -
Gode}: y +
❑ Misc.Conduits&Conductors � �. �
1,as ownet of the property,will do the work and ihe structure ,
is rot iMenfed or otfered fw sale(Section 7044,Business Other(See Gomplete Fee Schedule)_ � ;, ; ,
and PmTessions Codej.
CONSTFiUCTION LENDING AGENCY � J � � r .�
I hereby affirm that thera is a consYruction lending agancy tor the
perfamance of die work fw which this permit is issued(Sec.3097, pERMiT FEE (�b-Totaq
Civ.C.�.
. .PLAN CHECIUNG FEE. . .
Lender's Name
PERMIT ISSUING FEE �
Lerder's Pddres - —
I cerdfy that 1 have reatl this application and state that the above TOTAL FEE `�,Qa
information is carect.I agree to compry with all County ordinances
and State laws regulating EleCtrical iring,and hereby autFrorize
represantatives his unty to �ter upon the above-mentioned
property fo � ti rpo SEE REVERSE FOR EXPLANATORV LANGUAGE
� l/;�l- � ,� I
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