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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 .1 -�- SignaWie of erm Ile . Date ' '"...i� .cd. 4�� = o =� _ �.cp ��v 9,aS- �`e.....s• � ` o 3�°`' d ' a-`c c • m „ � rn`� 00 3 0 ° �o �°.n m o c � ' o H �' � c.c � � Eti� nc °,��.' ¢.i o ° � dobg � V a � a J '� o'� a�', �' � m L c � ",? u�h � � aci m �'t� . Z' ir � � [ „ 'i � N G C `u � -C G �,� E.� � C� I � L v�! � Q,p ti. U u� �a �-nC A�� O'C O A�i p 4 O n O O t � � � ooC E „ Q�o. ��s '> c, --m� ca n.m r. Q, I f q .._ a ,; .. m �, 3 b � o n K�, I i . , U a � •1 'JOfOd �� em £ �� 4 'Qp.c ° AS G� l ( ' . 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