HomeMy WebLinkAbout1370 VALLEY VISTA (54) WORKERS'COMPENSATION DECLARATION 78A663 ,0�8, qppLICATION FOR ELECTRICAL PERMIT �
I hereby aFfirm that I have a certificate ot caisent to selF insure, �'aoec �
or a certificate of 4Yorkere'Compensatbn Insurarica,or a cerUtietl COUNTY OF LOS ANGELES BUILDING AND SAFETY I
copy tp�reof�^�ec.'f38(0�Q{Lab.C.) t \!� � (
POIiCy� -..��`C t��py�Y���1{�.\i"a�V'�J FOR AFPLICANT TO Flll IN J09 �7-y (
� EACH NO. FEE ��E� '"'"� � } .F
Certified copy is hereby furnished. New Residential Bldgs.&Pools
� Certified copy is tilad w the county building ingpection ��2-Family,Sq.Pt $ -^ $ �OCALITY t '� y
depart nF Multi-tamily Sq.FL NEAREST �� �,*� :-.` ,
..5 CROSS ST. .�. '•.��y '•� � Y
Date�� ��Appiicar�f ''� AesMentiel Swimmirg Pools OWNER OR
. . � ^� ♦ FlRMNAME ��. 't .. �.r-�:tiif`_a
CERTIFIGATE OF EXEMPTI�7N ROM N/ORKERS' � � l�. „..: �nai� ":Y- �.,
CAMPENSATION I RANCE Outlets:Rec Ligh Sw..,.�� �/3 1 v' qpp�Es� ' '. �
(it�ls section need not be completed if the work inrdved 6y the ,� first 20 , �_
Total No.�.�._� Additional .. i'CITY� ���t� �_�ti {;� Tel.Na � -
permit is fa ona hundrad dollaro(5700)or lass.) .
1 cerEify Mst in the performar�ce of the vrork tor wttich this permit PLAN CNECK,
. 15 issued,I shall rrot empby arry person in any manner so as to �� APPUCANT
�':
become subject W the Workers'Compensation Laws. Lighting Fiztures Pirst 20 AD�RESS
Additional r0 i
Totai No. GITY ' Tel.No.
�ate aPPlicant Fixed Appliances Not Over 1 HP
NOTICE TO APPI.ICAN'F: If, after makin9 this Certificate ot P��� � � �4� : �" , �F{"
E�remption,you should become su6ject to the Workers'Compensatbn Rarx,7e_ Heater_ D.W. _ ,
provisions of tAe lahor Cotle,you must forthwith comdY W�th such Oven_ Dryer_ W.M._ A�DRESS•�. i ` , '`"
pNvisions or this pertnit shall 6e tleemed revoked. Top �FAU _ W.H. � " ,� r. ,
LICENSED CONTRhCTORS OECLARATION Hood_ Fan _ Other� C� �tS��,S:�.[J!�K+�k5,,.,�s�j C��-�Tel.N��,��t a;r �
I hereby eNirm thaf 1 am licensed untler pro�sions oi Chapter 9 LI ENSE OP .�--- ('y '
(canrrencing arith 5ectbn 7000)ot Division 3 of the Business and pisp. -- Room Air Gond. � qEG.NUMBER�t'��� E ��4 i'�` 3
Professions Gode,and my license is in tull force and effCct. � O�S7RtGT NO. �+OCESSEO.BY � '' �
Power Apparatus 8 Large Appliances j�` . �, O i
�'�1, Size&Type HP,KW,KVA,or KVAR ��.S��i ,���\��; '� � U �
License Number �� ` t'^-� Lic.Class�'� Up to i Incl. FINAL -� iq
-� �. Over 1 to t0lncl. i
Cwrtractor���-��i._1.�Y�.fi.�-��� 1 Date� �.'��C �:�' Over 10 to 50 Incl. PATE VALIDATION � i
�
❑ �am exempt under Sec. Over 50 to 100 Inc. gy� Q �
BdP.C.tor this reason Over 100 � �
Services,Sw6d.,MCC 8 Panelboards � i
�ate: 0-200 Amp.Under 6D0 V W �
Signature 207-1000 Amp,Under 600 V H �
❑ " � Ovar 1000 Amp.a Over 800 V �
Exemption for Reg.Maint.Elect.
�
SINGLE FAMILY Temp.Power Pole&Appurtenances ' �
HOME OWNER-BUILDER�EGLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt hom the Corrtrac[or's License Law
� for the followirg re2son(Section 7037.5,Business and Professions Addi�ional Sgn Branch Circvits �
COde):
i
a� Misa Conduits&Condudors .;.>;��•�i�
I,as owner of ihe property,will do the work and tFw siructure �
is not intended or offered for sale(Sectbn 7044.Business a�r(See Complete Fee Schedule)_ � e,t +��s,s,�� �
' and Professions Gotle). � .,... ;
CONSTRUCTION LENDING AGENCY � � ;��� } ~,�'�'�°^�'�'" J
. I hereby aftirm that Mcv'e is a constructan lending agency for the r',a.f,F,,�,f..�,;,�. �
peAortnance of the work for which this permR is issued(Sec.3097, pERM1T FEE � (Sub-Totaq � . �
Civ.C.1. ".'..
PLAN CHECKING FEE � �. �,c,c.;'"�::4�
Lender's Name
PERMIT tSSUING FEE - �
Ler�r's Adtlress
1 certiry that I have read thie application and state that the above TOTAL FEE '"�("4 �P. �
intormation Is correct.I agree to comply with all County ordinances
ard State laws regulating Electrical wiring, and fiereby authorize
r santatives of ihis County to enter upon the above-mentioned �
prop ty �ins c n r�es. - $�E REYEpSE FOR EXPLANATORY LANGUAGE
�.��..�3�� �-z L
Signa re f PermRtee Oate �
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