HomeMy WebLinkAbout1370 VALLEY VISTA DR (32) (2) WORKERS'COMPENSATIONDECLARATION , za°°w°"W3ie� qpp��CATION FOR ELECTRICAL PERiVtlT �
I hereby;qffirm thot 1 have a certificote of consenY to seif ���
CE eoaG ��
�c�ure,-or a certificate of Workers Compenwrion�nsurance, COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS
or a wrtified cop th f(Sec. 6.C.)
PoliCyN�--[y���Compa FORAPPIICANTTOHIIIN JOB ��/� R �
�Cerrified copy is hereby furnished. New Residential Bldgs.8 Pools �CH t�o. FEE A��RE ��
Certified copy is filed with the couM b ' inspec- 1&2-Family,Sq.Ft.
; _ b toC/+ur '
�ion de� Mu�ti-family Sq.Ff. — NEAREST �
CRO55 5T. �./
� A li Residential Swimm.ien1g Pools OWNER � /
1 PP /,$$ a FlRM N
� ���}`1 �TiFICATE OF EXEMPTION FROM WORKERS' Outlefs:Re��Light_Sw. `�
COMPENSATION INSURANCE �� Q ,S � ADDL �
This sxtian nwd nW hr cn First 20 G� �� �
( mpletad ll Nw wnrk i�wd�ad by Total No.� Additionol � 1h
fha parmif is for ona hundrod dollars(5100)o�less.)
vinN cr+e
I certify that in the performance of ihe work for which this AP�U fG
permit is issued,1 sha41 not employ any person in ony manner �
so as to 6ecome subject to the Workcrs'Compensation laws. li9hting Fixtures First 20 •�S n d ADDR r v
$ Addi�ionol , � e r�
Tofal No. q� � � d
Date Applicant Fixed A liances Nof Over i HP � 1-�
[r �CE TO APPtICANT: If, ofter making this Certificate of PP PERM�T /.�_�T �
4 ption, you should become subject fo the Workers' Range—,Hearer_D.W. _ A����� L�CCi�
Compenwtion provisions of the Lobor Code,you must forth- Oven —Dryer _W.M.— ADDR � O`'. �
with comply wilh such provisions or this permit sholl be Top — FAU —W.H.—
deemed revoked. Hood —Fan _Other_ �,� � ?Q.� �el.�f,j���� ,� �
LiCENSED CONTRACTORS DECLARATION ttCENSE OR
I hereby offirm lFwt I am licanaqd�nder provisions of Chapter 9 Disp. _ Room Air Cond. — RE[;.NUM� �� Cla .
(commencing with$ettion 7000)of Division 3 of the Business power Apparatus 8 La�ge Appliances DISTRICT NQ. PROC SED BY �
and Professions Code,and my license is in full force and effect. �� ��� O
�jti'Jy� �Y/ Siza-$�Type HP,KW,KVA,or KVAR ,` t
li<ense N mber-3 vry Lia Clas �� �• `�[ �1p fINAL
� Up to 1 Inc�. U
�� ` £ �`�, Over 1 to 101�cL �ATE YAGDATiON ¢
Over IO to SO Incl. � FfNAL O
❑ 1 am exampt u�der Sec. � Over 50 to 100 Inc. 7`�- a BY W
8.&P.C.fa this reawn .� Over tOD � O a
Date:
Services,Swbd.,MCC 8 Vaneiboards N
Q-400 Amp.Under 60p V � � Z �
Signoture 201-1000 Amp.Under bpp V 1 b �
� Over 100p Amp.or Over 600 V
Exemption for Reg.Maint.Elect. �
SINGIE FAMIIY Temp.Power Pole 8 Appurtenances /�fl���
HOME OWNER•BUILDER DECLARATION �
� eby affirm that 1 om exempt from the Conhactor's License Sign with One 8ranth Circuit �- f
Add'rtional Si n&anch Circuifs �
�,.n for the following reason{Section 7031.5, B�siness end 9 �J$//��
Professions Code): ( ���� 3 F
❑I, as owner of the property, will do Ihe work and the Misc.Conduits&Conductors v
structure is noi intended or offered for sale(Sedion 7044, Other(See Camplete Fee Schedule� � ff�' ' ' '�
Business and Professions Code). � ,.2 6�,��
CONSiRUCTION LENDING AGENCY
f hereby affirm ihat there is a construction lending agenty for • i.2 b�.v C c=i
the perfwmance of the work for which this permit is issued PERMIT FEE (Su6-Tmal)
(Sec.3097,Civ.C.). t��2 9"��
PLAN CHECKING FEE
Lender's Name
" PERMIT ISSUING FEE I O �
Lender'sAddress ' a w'a
I certify ihat I have read this app'mion pnd slate�ha1 ihe
TOTAI FEE ��
v6ove informotion is torrect.I agr e o comply with all County
ordinan Siate laws reg afi g Electriwl wiring, and
hereb aothor� repr tiv s o this Couniy to enter upon
et� e e prope fo inspec�ion porposes. -
����� SEE REVERSE FOR E%PLANATORY LANGUAGE
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Signature o Parmi�tae p�fe Q7s I
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