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HomeMy WebLinkAbout1370 VALLEY VISTA (80) . WORKERS'COMPENSATION DECLARATION CEAs06G ���81 QppLIC�.TION FQR ELECTRICAL PERMlTs�'i-S� J'j I here6y afiirm that I have a certiticate of conserit to self insure, y ' : Cor a certlfi ate of Nbrke.rs���pensatio - ra��orra;ertifie COUN7Y OF LOS ANGELES BUILDING AND U I �Py� � � � �. G Compan FOH aPaLICANT 70 FlLL IN JOB � Cer'ied Copy is hereby furnished. New Residential BIdBs&Pools EACH ND. .FEE ADORE55 � Certified copy is filed with the county buildinq inspection 1&2-Family,Sq.Ft. $ — $ LOCAL Y� d itment. MUI[Ffamily Sq.Ft. — NEAFEST CF105S 57< Residential5wimmin Pools Date AppliGan �> 9 OWNER OR � �� FlRM NAME CERTFFICATE OF EXEMPTION FROM WO KEflS' Outlets:Re�Light?�1 Sw.�L t� MAIL CAMPENSATION INSURANCE � nooae (Thla seciWn�d not 6a com�led q!he work im by Yhe First 20 � Total No.� qdditional CITY Tei.N parmit is lor one huntlretl tlol�rs($100)a less.) �� 4 certify ihat in ihe performance pf}hy work fw which this permit PLAN CK ' . is issued,I shall rat em APPLICAM ploy arry person in any man�er 50 25!O _ become subject to the Workers'Compensation Laws. Lighting Fixiures .+7 First 20 I 5 ADDRESS .t � Total No..�L �ditional Date Applicant CITV Tel. � �-� Fixed A liances Not Over 1 HP � �E TO APPLICANT: It, after makina this Certificate of p� PEatnlT ��, � JtiOn,You ehouid Gecort�e sutl?ct[e ths Workers'Cqn�BnSfltiOn �^9e— Fieater_ D.W. _ APPLIGANT . pcovisians of the latwr Code,you must£orthwith cwnply wi�h such Oven_ Dryer_ W,M._ AD6RE$LS � �'� 1 provisions w t�is permit_ehal!be deertieU revoked. - Top _ FAU _ W.H._ ( 3 LICENSED CONTRACTORS DECLARATipN C�T �' � Tei. � Hood--y Fan _ Other_ .f I hEfCby aff�m that t am.Icensed under prrnisions Of Chapter 9 / LICENSE QR (comrtfenCing wiFh Section 7006)of Oiv�vion 3 of the 8usiness and Disp. Y— floUm Air Cond. _ t7EG NllutE3eH �� ProFessions Code,and my license is in full force and effect. oisiatCr ra0. PHOCESS D ev � Pawer Apparatus&Large Appliances i �? �T � Size&Type HP,KW,KVA,or KVAR 1 O � ��.� "+� � License Num� Lia Class �—� Up to 1 Incl. FINA� � g Over 1 fo t0lncl. �ATE � a. � ContraCt 'Date ���—e �v�t>� VAUDAiF�N � � Over 70 to 54 Inci. FINAL ❑ I am exempt und r Sec. Over 50 to 10�Inc. BY W B$P.C.for this reason Over 100 �..�� a� � � Services,Swtrd.,MCC&Panel6oards � Z � e 0-200 Amp.Under 60�V � Signature � � . � 201-7�00 Amp.Ilnder 600 V ] / Over 10�0 Amp.or Over 600 V � ❑ Exemption ior Reg.Mai �eCt. { SINGLE FAMIIV Temp.Rower Pole 8 Appurtenances � . HOME OWNER-BUIIDER DECLARATION Sign wilh Oe�e Branch Circuit � ` :by affirm that I am exempt from the Contractor's License Law `n .ne toilowing reasar(Seclion 7031.5,Business arnt Professions Add+tionai Sign&anc�Circuits �1: � ❑ i,as owner of 1he property,will do the work and the structure Misc.Conduits&Conductas � is not iMernied or offerad for sale(Section 7044,Business Other(See Complete Fee Schedule)_ _; ,� - and Professi�ns Code). - � " - CONSTRUCTION LENDING AGENGY � �• � ` " � . I hereby affirm that there is a construction lending agency for the � - perFormance of ihe work tor which this permit is issued(Sec.3097, PERMfT PEE � �u`� Civ.C.). / (�b-Totap / V ��� PLAN CHECKIN6FEE � E " ` � Lender's Namel•Es �/f PERMIT ISSUING FEE 1� � ,•� `' �� �� Lender's Address���!f��j j�� 1 carti(y that I have reatl thls application and state that t� TOTAL FEE 1 information is correM.I 8gree to Comply with ail Cwnty ordinances tp and State laws regulating Electrical wiring, and hereby authorize represeMatives of tbi� ounfy to enter upon the above-mentioned property tor� p y SEE REVERSE FOR EXPLANATORY LANGUAGE I Signaty of py 'te j ^�/Date `� ! � / i " � � �= �;:�� �� � " "� � � - :..�:�, = o� . -. . _ � m J'�.��o ,� a,�� .n'a � �� �' °° , . - �% GJ Rf J _ C �i � Z .�� £� 0.� � ��M .V O ���'�Cl;� " � ' , . � A N . 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