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HomeMy WebLinkAbout1370 VALLEY VISTA (83) WORKERS'COMPENSATION DECLAAATION �sass3 �o�a� AppLICATiOIV FOR ELEC R�L �ERIYI�T I herehy affirm that 1 have a certificate oi consent io self insura, �'BO6G � i or a certificate�Wwkers'Gompensation Ir�surance,or a certified COl1NTY OF LOS ANGELES BUILUING AND SAFET`I[;.�L � copy (S c.3800,t.ab.C.) ^, ^l, . . ��`Yk PoIiC . �� (`,pmP�y�t�+��"+�'M� POR APPLICANT 70 FlLL IN JOB { `�s ❑ Certified copy is hereby fvrnished. EACH- NO. FEE ��ESS ,3 i�}'� _ _ . _. , New Residential Bldgs.&Pools �Cartified copY is ided wi the countY but�din9 i Pection 1&2-FamilY.Sq.Ft. $ — $ lOCA1JTY�t�� � dBpaRm t �: - . . Mulfi-farnily Sq.Ft. — NEAREST Date i L � . _ ... CR0.SS ST.� � � Residenfial Swimmirr s ^• �+ ,¢'� .,4- -- ---- ---- AppliCant . _ I� j ORMNAME pvd� LI.J'S 1 , � CEH7IFICATE OF EXEMPTI OM WpRKERS'. � p�tlets Rec�Light Sw..� CU,I. .0 e 7+ `VLD COMPENSATIQN W GE� �ADO Ess (TM9 sectbrc need not ba completod if the work hrvolYed by the First 2� �` � �� ��is � permk ia for orre hundred dWlaes(St001.�less.) � TMaI No. � Add'd'anal py CITY �� Tel.N Q. 1 4 certity that in ths p�tamance oi�the�wak ia whicM ktus permit PU'�e�� � �j �� 1 is issued,I shall not ert�by any person in arry manner so as to ,�5 APPLICAN7 � became subject to{he Wwkers'Compensatan Laws. Lightir�Fixtw- First 2o S!/+� ADORESS�,�.�iQ � Total No. '�'� ���al fl'U �� � Date Applicant CITY �,}. � -. Tei.No. � NOTICE TO APPUCANT: If, after making this CerYrficate of Fixed Appiiances Not Over t HP PERMIT� ♦ �.� ` 1� ExemWion,you ahould hecnme subjectto the Workers'Gompensation Range_ Heater_ D.W. ����`Nr v���l..F.? • pmvisions of the Labor Code,ypU InU9t forthwith comply with such Oven_ Oryer_ W.M._ A�DRESS� .f�..'�1C�.►.�:� � Drovisions or this peGmit shall be deemed rewkeU. Top _ FAU _ W.N._._,_ l � UCENSE�CONTRAGTORS DECLARATION �TY . ,y �cT Tel.No. � { Hood— Fan .,_ Other_ 1 he�eby affirm that!am Gcensed under provisions of�Chap[er 9 uCE�Of7 � Oisp. _ Room Air Cond. _ (cammex'uu�{with Section 7600)ot Division 3 of the Business and nEG.NUMBER . �� �1i 3 Professbna Code,and my license is in fult force antl effect. OIS7AtCT NO. �� PRpCE�D BY � 3 Power dpparatus&Large Appliances F Q Siie&Type HP,KW,KVA,or KVAR �i � o 0 License Num6er � O Lic.Class�� Up tn t IncL EINAL (� _ ConhaCta y��.7+L��+�+•-+ Date ���.� Over t M 10 Incl. OATE y�^��c yALfDAT10N � i Over 10 to 50 IncL � � 0E- ❑ I am exempt untler Sec. � Over 50 to 700 Inc. Fl�� U � . gy 1rt . _� W 4 6.&P.C. this reason Over 100 V" a� i Services,Sw6tl.,MCC&Paneiboards � Z j Oate: D-2D0 Amp.Untler 800 V s�a�c�re 20�-y000 n�,p.u�de�sao v � � Exem ion Over 1000 Amp.or Over 600 V pt� g.MainL Elec[. � INGLE FAMILY Temp.Power Pde 8 Appurtenances HOME OWNER-BWLDER OECLARATION Sign with One 8ranch Circuit i here6y affirm that I am ezempt from the Contrac[or's License law .p��pnal S�n&anch Circuits '� (• ` � for the folbwirg reason(Section 7037.5,Busi�ss and Professions � �:E� , �- y Code): ' i � Misc.Conduits&Conductors � i � ° e - -. � !,as owner of the property,will do the work and the structure i is not iMefded ar oflered tor sale�Section 7044,0usiness ����r(See Complete Fee Schedula)_ � � a ���' _� , and Professions Code�. - a �. a� � - - CQNS7RUCT10N LENt?ING AGENCY . .. - -- _.- � ` T . ------—— - ----- ----.... . I hereby affirm that there is a construction lendirg ageray for the - -� -� � �-� --- �7(� �-�1_ ��, - performance of the work for which thia permit is issued(Sec.3097, . `�pERMIT FEE- �Su�Total) - �' � � � Civ.C.1� . . ...... ... .. . . . . .. . . . ; . . . _... .... ..,. ...'._--- ,_ .. . .. ...,..... .. . . . . ._... . . ...... . �PLMI CNECKING FEE Lerder's Name ^' �- . ..._�. ....----- jPERM1T I$SUING FEE � {/ Lender's Adtlress S I cerCfy that I have 2ad this application and sfate ttat Me above iAL FEE ��,� information is correct 1 apree to comply with ell Camly adinances - arid State Laws�e�lating Electrical wiring, end hereby euthorize representatives of[his County to enter upon Me abo�e-mentioned � - - � �,property for ins �pn purposes. � n w �� �� SfE REVERSE FOR E7fp1,ANATORY LANGl1AGE _. C y� S re of Permittee Date - � �-�. . .. ..., . t .. . J� .. , . ' ...,,�w•: N,.�� 6 t , ' ' ' ' `� � p w � ,Na � � � . . ; 3 � N L L, ,�.'c'„�� �'- `.� O � � ��^ �ti" . 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