HomeMy WebLinkAbout1370 VALLEY VISTA (86) WORKERS'COMPENSATION DECLARATION 76A663 ioiBt APPLICATIOiV FOR E1�CTRICAL PERMIT �
I hereby offfrm rha�I hare a certifimte of conseni to self �E-�
insure,or a certifitote of Workers'Compensotion Insurance, COUN7Y OF LOS ANGELES BUILDING AND SAFETY
or a certified copy thereof(Sec.3800,Lab.C.) ��
P❑ol�icy No;��•-) Compony�l��/✓I FOR APPLICANT TO Flll IN JOB
Certified copy is hereby furnithed. New Residential Bidga.&Pools EACH No. FEE ADDRE55 �
}�-�/ 1&2-Famil F. s — S LOCAIITY
�7C� Certified copy is filed with the county building inspeo ri S4•
/`��ion depar ent. Muiti-family Sq.Ft. — NEnRE57
���?����'� Residentiol Swimming Pools CROSS 5T.
Da�e Applicanl OWNER OFt �
/�� FIRM -
CERTIF CATE OF EICEMPTIDN FROM WORKERS' putlets:Ret�ScYLightlSw� � .,� � oDRE55 c�;��ZSf[� �/ �L �'9
COMPENSATION INSURANCE �� First 2p
(Thia sacilon nNd no1 h*somptaled if!h�wnrk invoMrad by Toial NoC� Additional ' ITY Tel.No.'Lt3� 's
tit�p�rmil ia for on�hw�drvd dollors(f1W)or IM�.)
i certify thot in the performance of the work far which this �'pp��qMK�
pgrmit is issued,1 shall not empfoy any person in nny manner
so as to become subjec�to the Workers'Compensation laws. lighting Fixtures First 20 AD6RE55 - 7� ! (�)N�
Additional �
Tolal No.� ITY f el.No. �
Date Applicant POL�/'�"]' l7S �J d 'L -' �' - ��
^r„ Fixed Applionces Nof Over 1 HP p�T �
E TO APPLICANT: if, ofter making this Certifimte of APFLKANT �
f lion, you should become soblect to the Wwkars' Range_Hea�er�D.W._
� ,�„pensation provisions of ihe Labor Code,ya�mus�forth- Oven _Dryer _W.M.� AD�RESS '[J
with compiy wirM s�ch pro�isions or this permit shali 6e Top _FAU —W.H._ � �
deemed revoked. Hood _fan _Other_ CITY � Tel.No.
UCEfYSED CONTRACTORS DECIARATION p� _Room Air Cond- — LICENSE OR` 'L�Q C !1
I hereby aRirm thot!am licensad under provisions of Chapter 9 �" REG.NtlMBER �7" I���,J ��Ou•�-(r } j
(commencing with Seciwn 7000)of Divisian 3 of ihe Business DISTRICT NO. PROCESSED BY �-
Power Apporatus 8 Large Appliances
and Professions Code,and my license is in fuft force and effed. �j-�� O
��/ ^ (j� Size Type HP,KW,KVA,or KVAR w A r/f � � V �
Litense Number Y.'��Lic Class <�f�+� �'Up to 1 Incl. •� ..� DA E` 0 �
fI Over 1 ro!0 Incl. ! �� �S VAIIDATION }
Contratlor Y1�1-E-����.Dote '� �_ Over 10�0 50 Incl. � FINAL ( ` � � �
❑ I am ezempt under Sec- �y. Over 50 to 100 Inc. BY /�
B.BP.C.for this reason —Lr- Over 100 C �
Z �
pa�e_ Services,Swbd.,MCC&Panelboards � .Z p � . 8
0-2(70 Amp.Under 600 V �
Signoture 201-100p Amp.Under 600 V �'6 2 G,�C
Over 1000 Amp.or Over 60p V
� Exemplion fo�Reg.Moint.Elet�. �� � � �� 9 �
SINGIE FAMILY Temp.Power Pole 8 Appurtenonces f •5 5 6 2 'rj �
, HOME OWNER-BWLDER DECLARATION Si n wilh One 8ranch Circuit
:� 1�r y affirm that 1 am exempt from the Contracroi s License qddifionat Sign Branch Circuiis ' - - ' �`���"''�'�
, w�.. �r rhe following reason(Secrion 7037.5,8osiness ond ,
�
Professions Code): O Z� 7� �]
❑ 1,as owner of the property,will do the work and the M!sc.Conduits 8 Conductora
structure is not intended or offered for wle,(Section Other(See Complete Fee Schedule)_ �
7p44,Businass ond Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm thot there�s o construction lending agenty for
the performance of the work for which this permii is issued PERMIT FEE (Su�Total) �� �7,$a
(Sec.3097,Civ.C.).
PLAN CHECKWG FEE � S O �• �� • •• ��
lender's Name
PERMIT ISSUING FEE Q I }� L;..O C1
lender's Address
I certify thar 1 hove read this application and stale Ihai the TOTAL FEE ,J� � 'I�� �.'i U v w
o6ove infwma�ion is cwrect 1 ogree�o mmply wah all County
ordinances ond S�ale law:regolating Elecfrical wiring, and �L G b`3 7
hereby authorize rapr sen� � es of ihis County 10 enter upon ` , _
, the obove-menti nr pr ty for inspeUion purposes.
SEE REVERSE FOR EXPLANATORY lANGUAGE
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