HomeMy WebLinkAbout1370 VALLEY VISTA DR (51) WORKERS'COMPENSATION DEQARATION TO-0079DPW3/Bl APPLICATION FOR Ei.ECTRiCAL PERMIT I j
I hereby cffirm that I have a cenlfiwre o4 consent fo seif ��
insure,or a certificate of Workers'Compensotlon Insurance, COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS ��
or ter�fi Qtop� �hereo�Sec.380Qj�"'��a(bCC.���
Pal a«� omppny `�'—�• fOR APPLIGNi TO FILL IN )p8 � (
�JCertified copy is hereby f�rnished. New Residentiol Bldgs.&Pools EACH NO. FEe ADDRESS
'�]QCariified co is filed wi fhe tount buildin ins ec- 1 8 2-Fpmil S F�. _ ��A��nT p
PY Y 9� P Y, 9� 5 — $ ^'����0 �'`
�hon de arim i Mulfi-family Sq.ft. I�AREST/'� �j
.� ���� � CROSSST\.�)(�I �I+i�
Date Applica t Residential Swimming Pools OWNER OR �.cT �t�
�/ry FIRM NAME vJ C � �J
CERTIFICATE OF EXEMPTI ROM WORKERS' putlets:Rec�f¢Light 'Z�Sw.1L �'�� �^7�
COMPENSA710N INSURANCE �q� F.5�p � 5�ADDRESS�,I,JCIJVr}�, ����
(Thts aeefion nwd mf fw complNod if tiw work involrod by Total No.�LL q���ional 0 / s 5 �� W � N �
fhe parmii is far o'w hundrod dollars(s100)or less.) PLAN CHEC (�r�„�
w
I certify that in the perfwmance of the work for which th�s ppp��GqNT� �� �-�w�jJ
permit is istued,1 shall not employ any parson in ony manner ��, �
so as to become subject lo the Workeri Compensation lows. �ighting Pixfures Pirat 20 '� �r� ADDRE ��
9vr) Additional �
+� Tolal No.�.Q�. S CIT � , t
l.�iICE TO APPLICANT�.�If 11aft tr making this Certificale of Fixed Appliantes Not Over 1 HP 7 � `f3 � PERMIT
Exemption, you ahould betome subject �o the Workers' Rpnge— Heater—D.W. _ APP�i�AT�ON p
Campensa�ion p.ovisions of iha La6o�Code,you must forth- Oven — Dryer _W.M._ ADDRE '3 6r �il, D�
with tomply with such provisions or this permii shal� be Top — FAU —W.H._
deemed revoked. Hood —. Fon _Orher— CITY "��� Cd Tel.No. ��
IICENSED CONTR.4CTOR5 DECLARATION tICENSE OR 11 SZQ� Clas� �
4 hereby affirm thot I am 14censed u�er provisions of Chopter 9 Disp. _ Room Air Cond. � �
REG.NIJMBER '�i
(commencing wilh Section 7000)of Division 3 af the Business power Apparot�s 8 large Appliances DISTRICT NO. PROCESSED BY ]� �
ond Professions C de,and m license is in full force and effect. /� d
c (� h Sixe&Typa HV,KW,KVA,or KVAR p
License Nu r J V � Lic.Class �v � U
Up ro I Incl. � � FINAL
Over 1 to 10 Incl. .fI7� DATE e_ c YALIDATION �
Controctor �ata...... � ,[N � ����� '�� 0
❑ � Over 10 to 50 Incl. FINAL �
I am exempt under Sec. Over SO to 100 Inc, � ' HY W
B.BP.C.for this reason °�' Over 100 �• �-0 a
Services,Swbd.,MCC 8 Ponelboards �
Dale: 0-200 Amp.Under 600 V '�L .30 � �
Signat�re 2p1-1000 Amp.Under 600 V 0•NJ �D [R)
❑ Over 1000 Amp.or Over 600 V
Exemption for Reg.Maint Elect. ...�4 (,v�
SlNGLE FAMILY Temp.Power Pole 8 Appurtanantea
� HOME OWNER-BUILDER DERARATION � � ,,� : � s • •L
I hereby affirm thot 1 am exempt from the Contractor's License Siqn with One Branch Circ�it � �
Law for Ihe foliowing reason (Section 70.31.5, Business and Additional Sign Branch Circuits � i.c..(: (,.U 4
Professions Code): e , _
❑I, as ownar of the property, will do the work and the Misc.Conduits 8 Canductors "'" �'"�"�"
svucture is noi intended or aHered for sale(Section 70I4, Oiher(See Complete Fee Schedule�. � v� ,'�,_�£
Business and Professions Code).
CONSTRUCTION IENDING AGENCY
I hereby affirm that there is a constr�ction lending agenty far
the performance of the work for which this permH is issued PERMIT FEE (Sub-iotal� Z� �
(Sec.3097,Civ.C.).
PLAN CHECKING PEE
Lendar's Name
PERMIT ISSl11NG FEE ��
Lender's Address TOTAL FEE �
1 certify thm I have reod this applicmion and state thot the .Z,�p`f,(�Q
above informotion is correct.1 agree to comply wilh oll CounN
ordinances and Stale bws regulating Electriwl wiring,ond � ���
hereby ou�horize represenralives of this Counry to enter�pon
e a6ove-m nti nad properry for inspection purposes. SEE REVERSE fOR EXPLAHATORY IANGUAGE
C� 3-2�5-��
Si no re of Permitlee Date ��
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