HomeMy WebLinkAbout1370 VALLEY VISTA (79) i
�ORKERS'COMPENSATION DECLAR4TION 76H663 �0,8, pppLICATION FOR ELECTRICAL PERMI� {�
. ,Affirm that I have a certificate oF consent to seff insure, C68oeG ���
�frficf te of Workers'Compensation rance,or a certitie COUNTY OF LOS ANGELES UIL AND�F Y u
� a
' ��mpen�`-- FOR ApPLfG1NT TQ Fl�,IN JOB
f( C �fied copy ia her@by furnished. H NO. FEE ��E� �� �/ �• C
New Resiaemial Bltlgs.8 Pools �OCALfTY
� Certifisd mpy is tiled with the couMy � in � pect' 7&2-Eamily,Sq.FL � — $ 1
� depariment. Multi-family Sq.Ft. — NEIWEST
CR0.5S ST.-��� 4
Date�� Residential Swimmi�Pools . . . �
` aodicant owNEa oa
CERTIFICATE DF EXEMPTIO FWM hiat+fE ��
,� -� CAMPENSATtON � -- -- .. .. .. � Outlets Rec�Light�w.� C MAIL
First 20 I J O AODRE3S i i
(This section rreed not be completed if the work invol�ed by the GTY Tel.
permit ia ta one hwMred doilars(S 1001 w less.) Total Na�33 pdditional 5 �
1 certify that in the performance of the vark for whbh this permit PLAN C CK . �
is issued,i shall rwt employ erry person in any manner so as to APPLICANT
become subject fo the Wakers'Compensation Laws. LiOMifg Fiztures First 20 I� O AD�RESS ,
Additional
" TMaI No. CITY Tel. ' „� �
Date Applicant Fixed Appliances Not O�er t HP PERMIT
N ":E T6 APPLICANT: If, efter making this Certihcate of �
� �10�I�YWI S{iC1UIO bBGOR18 SLI�1�6L�t01{IB YJOfk8F5�CORI�Elifidtlqfl APPLICANT
Ranpe._. Heater_ D.W. _
provisions of the Labor Code,you must forthwith comply with such Oven _ Oryer_ W.M._ ADDRES
prrnisions or fhis permit shall be deemed revoked. Tqp _ FAU _ W.H._
LCENSED CON7RAC70R9�ECLARATJON. Hood— Fan _ Other_ Ct7Y F I.N — E
�hBre6Y aBirm that I am licensed under provisions of Chapter 9 Oisp. — Room Air Cond. — uCENSE OR
(commencmg with Section 7000)ot Division 3 of the Buairress and REG.�tuhnsE .� �7/"� �
Professiorw Code,ard my ficense is in tull force ar�effect. Power ADParatus&Large Appliances �tSmiCf IJO aaOGESS Bv
License Number� ✓ Lic.Class �—� Size&Type HP,KW,KVA,or KVAR � � f
Up to 1 Incl. FINAL C� !
� �� � Over 1 to 10 lnc4. DA� / y l G YALIDATION � 111I
Contract � Dabg, Over 70 to 50 Incl. • � 1
❑ FINAL f
1 am exempt u Sec. Over 50 to 100 Inc. gy
B.SP.C.for this reason a`�t�� �"' �
Se�vices.Swbd..MCC&Panel6oards � � �
Date: 0-200 Arr�.UrMer 600 V ""
SignaNre 201-1000 Amp.Under 600 V �
❑ Over 1000 Amp.a Over 600 V �
Euemption far Reg.Mai�t.Elect.
!
SINGLE FAMILY Temp.Power Pofe&Appurtenances �
HOME OWNER-BUI�DER DECLARATION Sign wfth One&anch Grcuit
; :by affirm that i am exempt from the Contractor's License Law
i. ie folbwing reason(Section 7031.5,Busiriess and Prolessions ����Sign BrancF Cira:ils g
C.odel: }
❑ 1,ag owner of the property,will do the wak and the strudurc Misc.CorWuits&Conductors `, i „ - �
is rwt in[erWed or offered fw sale(Section 7044,Business Other(Sea Compiete Fce Schedule)_
arid Professions Code). � t a « � - .. �
CANSTRUCTION LENDING AGENCY � � -
I �.4:' .
1 he2by aftirm that there is a consMuction lending agency br the ��
p�fwmance d tha wwk tor which this permit is issued(Sec.3097, pERMIT FEE (SutrTotaq . . ., ,� , �
Civ.C.). ' �
PLAN GHEGKING FEE j �,� �— . j
Lerxler's Name � �_ �O �� i
PERMIT ISSUING FEE
Lender's Address - i
I certiry thet I have read this applicetion antl state that the aCove 'f�TN.FEE �
informatron is cor2ct.I agme tn comply wi all Counry ordinarices
and State laws regula[ing Electricat , and hereby authorize
2D2sentative�f ihi� unty toyr�t upon the a6ove-mentioned
property�foc'3 rpos a� SEE REVER5E FOR E%PLANATOHY LANGUAGE
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