HomeMy WebLinkAbout1370 VALLEY VISTA (88) WORKERS'CDMPENSATION�ECLARATION 7sA55s �o�e� qpp��CATION FOR ELECTRICAL PERMIT 222 '
I I hereGy aNirm that I have a certificate oi consent to seif insure, �80�� �,1 �i
or a certificate of workers'Compensation Insur r cer � COUNTY OF LOS ANGELES BUILDING AND SAFETY n� �
copy thereof(Sec.3800,Lab.G.) ..
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PoliCy NO.'." � • � ."� "Company . '� :'i� - FOB APPLICANT TO FILL IN JOB . . I
❑ Certified copy is here6y furnished. ' y�w es¢e�al Bldgs.&Pools EACH NO. FEE A�RESS -^�`-�' ' � - � '�
' $ — $ LOCALITY
� CertiFied copy is f. .w n i tio "����2�Family,Sq.Ft: ` . -� . � ' � � I
department. � �,�ululti-fami�y Sq.Ft. — NEARE5T ,
QSte ' � • , -A�a��4 ���. ��ntial 5wimming Pools OWNER OR . ,
F�RM NAtv1E . . . �
CERTIFIGATE OF EXEMPTION FROM WOflKERS' p���y;Rec_Light_Sw.— �� r '
COMPENSATION INSURANCE AD�RE55 � '
(This section need not be completed'rf the work involved by the First 20 i
permit Is for one�undred dollaro[�700)or less.) Total No. AddRional CITY � . Tel.No. �� j
PLAPt CHECN �
I cer6ry that in the performance of the work for which this permit ���M `"'"���� I
is issued,1 shall not emplpy any person in any manner so as to
6ecome su6ject to the Workers'Canpensation Laws. L"ghtirg Fixtures Fvst 20 ADDRESS "^�—
Total No. ��t�
CITY Tel.No. �•
Date Applicant fixed Appliances Not Over 1 HP pEqMR
NOTICE TO APPLiCANT: If, afler making lhis Certificate of �p��T � , i
Exemption,you shouW become suhject to the Workers'Compensation Renge_ Heater_ D.W. _ - �
�provisions of the Labor Code,you must forthwith cvmply with such Oven_ Dryer_ W.M._ ADDRESS- �'•! {`-
provisions or this permit sha!I be deemed revoked. Top _ FAU _ W.N._ • �
LICENSEO CONTRACTORS DECLARATION Hood— Fan _ Other_ qTY"" `, ' � . , � Tel.�Jo.� , � - j
I hereby affirm that I am licensed under provisions of Chapter 9 p�p _ ������ _ LICENSE OR -" �
tcommencing with Section 7000)of�ivision 3 of the Business and REG.NUMBER - ��� �- �% =
Professions Code,and my license is in full torce and effect. dSTRICT N0. JPaocE55Eo Br �' �
Power Apparatus 8 Large Appiiances O -
� f �� -
� - Size&Type HP,KW,KVA,or KVAR `
� Licanse Number � � ' Lic.Class � Up to 1 Inc4. FINAL ' -� ;
' "' ' Qver t to t01ncJ. OATE Y. �
Contrector � Date ' VALIOAT(ON }� i
❑ Over 10 to 50 Incl. FlNAL a �:
1 am exempt under Sec. Qver 50 to 100 Inc. BY . � �
B.&P.C.fo�this reason Over 700 0 p
� Services,Swbd.,MCC 8 Paneiboards � Q"� '
Oate: 0-200 Amp.Under 600 V W �
� Signature � 207-1000 Amp.Under 600 V b �
❑ � Over 7000 Amp.or Over 600 V =
Exemption For Reg.Maint.Elect. i
1
SMGLE FAMILY Temp.Power Pole&Appurtenances �}
HOME OWNER-BUILDER DEGLARATION Sign wi[h One&anch Circuit "- •'�`�W�r t i
1 here6y affirm that I am exempt from the Contractor's License Law pdditionat Sign Branch Circuits „ �*'����M,-�� �
tor the folbwing reason(Section 7031.5,8usiness and Professions _ .,�:„, „,F„ �
Code):
� Misc.Conciuits&Conductors �=��z,��.�.�S.-;
I,as owner of the property,will do the work and the strucfure �
is rwt intended or oRered for sale(Section 7044,Business Other(See Complete Fee Schedule)_ � s�s' i�<S s:��
antl Professbns CoOe). r.:k:.i.�...-
CONSTRUCTION LENDING A�ENCY �''f',+'"'-"`4.
I hereby affirm that there is a construction lending agency for the �
pertormance of the work for which this permit is issued(Sec.3097, PEFMIT FEE (Suh-Total} � . �
Gv.C.). �
PLAN GHEGKING FEE �
Lender's Name �
PERMIT ISSUING FEE
Lender's Address - �
I certify that I have read this application and state that the a6ove TOTAL FEE ,.,r��:
information is correct.1 agree to comply with all County ordinances
arc1 State laws reguletin9 Eleciricai wiring,and hereby authonze
representatives ot this County to enter upon the above-mentioned .
property for inspection purposes. SEE HEVERSE FOR EXPLANATORY LANGUAGE
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, ignature o0 Permittee � Date �
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