HomeMy WebLinkAbout08_22_1985 - 21015 PATHFINDER RD i ,
WORKERS'COMPENSATION OECLARATION ;��3 ��,81 APPLICATION FO-R ELECTRICAL PERMIT � I
I he�eby oHirm that 1 have a certificote of consenl to self � -
insure,or a carYfimte of Workerg'Corvpeosation Insoron c��I COUNTY OF LO$ANGELES BUILDING AND SAFETY �
or a cer h fie d copy�hereo f(S ec.3 8 0 0,la b.C.) V � � -
�cy No.'PC974301 CompanyReptih 1 i c TndPmni ty FOR APPIIGM TO FRl IN 10B O 15 �7 N r 1 ��
Cerlified copy is hereby furnished. New Residentiol Bldgs.8 Pools FACH NO. FEE A��� �
O1&2-Fomil PL s — S LOCALITY .
Cerlified copy is filed wirh the county building inspec- Y�59•
lion deporlmenL . - Mulli-3amily Sq.Ft. — NEAREST
- - � Residential5wimming Pools - �� �ER� � �
Date R�97�R5 APPlicant . . � -
Q� FIRM NAME I
CERTIFICATE OF EXEMPTION FROM WORKERS' �j � ��� ht�L{LSw.�2 _ q�oo'REss Z •
���an:R� 7�r ac�
� COMPENSATION INSURANCE �� 2��9 - First 20�� � �.
(Thit s�dion noed nol b�tompl�bd tf th�work inrolv�d by Tmal No._iZS�L A�itionol 5� '] U CITY. .. Tel.No. 1 ?(� �
th�permN it for ona hundred dollen(5100)or Iea�.J . . �
I cerfify that in�he per(ormance of�he work for which this pajr��a,HN�:
_ pe�mit is issued,I shall not employ ony peaon in ony mannar ';
so as to bacome subjact to�he Workers'Compensa�ion laws U9hting fixtures First 20 -� S ADDRESS � � �
Ynry, Additionol t7 �
� - .�� - � . Totol No.�L CITY � Tel.No. •
Date - applimN ' Fixed Apptiances Nof Over.l HP � pErsnn�T �
NOTICE TO APPLiCANT: ff, aifer moking this Certificate af APttICANT � �i =�i � � '
Exemption, you should bemme subject �o the W«kars' Range_Heater_D.W._ , �
Compensation provisions ef�he labor Code,yov mvsr io.rh- Oven _Dryer —W.M._ ADORESS� �
wiih comply wifh such provisions or ihis pe�mit shall be 7op —FAU _W.H.— . � CITY � �Tel.No. �
deemed revoked. � Hood _Fon _Otber_ �,
� LICENSED CONTRACTORS DKLARATION tiCENSE OR n
I hereby oHirm thal l am licensed onder provisions of Chopler 9 � ���P• —Room Afr Cond. — REG,NUMBER � �( Class.G�� '
(commencing with Section 7000)of Division 3 of the Business Power Apporotos 8 large Appliances DISTRICT NO. PR BY . }
and Vrofessions Code,ond my license is in/00 fwce ond affect. - � d �
. 169577� � - - Size 8 Type HP,KW,KVA,or KVAR� � � (ZN+«� 0 -
Litense Number Lic.Cbss C1� -Up to 1 Ind. � FINAL . . / . . V .
� _��Over 1�o IO lncl. °O b DATE �pl„��1�1 yp��0AT10N �
Contractor ESSCO ELEC. oate $�z2�$5 FINAL V '
❑ . Ovar 10 fo 50 Ind. . . . . . . .
I om ezempt�nder Sec. Ovar 50 fo 100 Inc. BY � W
6. �
Over 700 N
B.&P.C.for this�eason .:��:1� ii Z ?
� -� � - Services,Sw6d.,MCC 6 Pooelboards - - . --� -
DO1e' 0-200 Amp.Under d40 V � �;a • • � ='�'
Signature � 201�•1000 Amp.Under 600 V � � � � -
❑ . Over 1000 Amp.or Over 60p V . . . jf . • • • •�
Exemption for Reg.Maint.Elecf.
SINGLE FAMILY ' •���C O
HOME OWNER-BUILDER DECLARATION Temp.Power Pole&Appurtenonces . .. e
I hereby affirm thot I am exempt from the Contmdor's License Sign wilh One Branth Circuit °��=�.��T
Addilionol Sign Branch Cirtuils�
Law for the following reoson(Section 7031.5,Busineas and . � - � - - O J G'J�-E�S �
Professions Code): . � �
❑ I,as owner of 1he property,will do the work and ihe � Misc.Conduits 8 ConduUors � � � � - � � -
structure is not intanded or offered for wle �Section ��her(See Complete Fee Schedule)_ � �
704A,Business and Professions Code). �
CONSTRUCTION LENDWG AGENCY � - � - � ��
I here6y affirm thol there is a mns�rottion lending ogenty for , �
the per(ormonce of the work for whith ihis permit is issued -- PERMIT FEE (Sub-Total) F� � � � � - � - - �- �
(Set.3097,Civ.C.). -
� PIAN CHECKING FEE - � � � �� - - � � �. �
Lender's Name - �
- PERMIT ISSUING FEE � � �O � � . .
Lender's Address � �f� O .
I cerrify thor I hove read this applimtion and stote thot the . TOTAL FfE V _
above information is mrrect.I ogree to comp�y with oll County . .
ordinances and Siate law:regulating Eledriml wiring,o�d _ . _. . . � Business License....._.._........ .
hereby authorize represeNotives of this County to enter upon , � �
ihe obove-men'ooe pro ry f inspedion purposes.
� SEE REVERSE FOR EXPLANATORY LANGUAGE �(pj1'�t10C1 L�'f9 ............--.-.--
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