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HomeMy WebLinkAbout10_09_1985 - 21015 PATHFINDER RD . WORKERS'COMPENSATIONDECLARATION ��� �a�B1 APPLICATION FOR ELECTRICAL PERMIT , ��..� �� I hereby off�rm�hot I have a certi(icate of mnsem ro self �E-� � . -�insure,or a teriifitote of Workeri Compensation Insurance, . COUNTY OF LOS ANGELES. BUILDING AND SAFETY � or a certifled copy rhereof(Sec.3800,Lob.C.J � • � P❑olicy No.�y��� r''��Compony< 1- ...:7�).'... ; FOR IVRICAM TO FRL IN JOB �� - ' CertJ'ed topy,is iC�eby furnished New Residential Bidgs.&Pools � EACH FEE AoorsEss �/�_• :�s '� / J� � , � �� 1 6 2-Pomil FI. s — 4 LOCAUTY Certified copy is filed with Ihe counly building inspec- Y�SQ• .tion depa�lmenl. ,- Multi-family Sq.Ft. ' — NEAREST . � ': ;If,: . . �� � • Residantial Swimming Pools . . . �ST r - r�,1. Dof %• �� 1! Appl¢ant .:. ,.. ! �1.� � . fIRM NMAE /-:�'7 -- , � : ���, �" . CERTIfICATE OF EXEMPTION FROM.�VORKERS' Outlels:Rec_LigM���`�Sw._ M�'�� ' ' � COMPENSATION INSURANCE }�, � .' : ADor�ss • � j ' This s�erien n�ed�rot b�eom I�Nd ti tha work inrolved 6 first 20 " - ; � th�permN is for on�hundred dollon(S100J or Isss.)_ r Tmol No. `��� Addilional ' � , �'; �.'. -� CITY _ Tel.No. � I certiFy rhur in the parformance of the work for which this - , PIAN CHECK ! � _. . . � rmit is issued,I shall not em lo on y ' APVLICANT t, /'-`:/.� /'�- „ ='( ��!:� ,� pe p y y per5on in on mon�er� � . , ��� - so as�o become sub'ect to ihe Workers'Com ensolion Lows. Lighling Fia�ures fi�sf 20 . - � qpDRE55"� � � - I P �..5:� . _rrl f�/ -1 ' . . � - . . . � Totel No. � Additional 'i : . Date ' � � opplicant � -� � CITY� /��� i,t �� � � ., Tel.No.'.; i NOTICE TO APPIICANT: If, offer meking this Certifimte of Fixed Applionces Not Over 1 HP � � PERMIT �F.- . � Ezemplion, you should become subject to��Ihe Workers' Range_Hea�er_D.W,_ - � ���`NT �� ��' ' ����� i Compenwlion provisions of ihe labor Code,you must forth- Oven —Dryer —W.M._ � � qDDRE55 . � � wifh wmply wifA svch.provisions or this permit sholl be Top _PAU � —W.H.— - .. deamBd revoked. � � � � � � � CIN - � � Tel.No.� � 1 � LICENSED CONTRACTORS DECLARATION ' Hood —ion _Orher_ � . I I hereby�offirm thot I om li[ensed onder provisions of Chaptar 9 Disp. _Room Air Cond. — `RE(3N UMBER 'f 1 .' ��an'C ' ��i I - {commencing with Section 7000)of Division 3 0(Ihe Butinesz DISTRICT NO. � PROCESSED BY ��� } i Power Appara�us&Lorge Appliontas� d ��and Profess�ons Code,and my Gcense�s in foll force and eHxt. . � � . : I - �' � 1 ' J /� $ize 8 Type HP,KW,KVA,or KVAR. � V � license Number-S �'/t- J' �' Lic.C�ass�� � Up to 1 Ind. � FINAL . ` ` W . / ' DATE � �" �'� •:'}l1 te- t:.� �.�� � Y� � ?T'�'�—.Ovar 1 ta 101nd.. . j: ,�, -� VALIDATION LL j � Conhacfo��'��` `- . . a Over 10 to SO Ind. T ❑ . . � .. � fINAL . � � . � •.� 1 am axempt under Sec. Ovar 50 to 100 Inc. BY Q B.BP.C.for this reason - � � Over 100 . . . „'j4��,t�7�i:p�. Q ! � � � Services,�Swbd.,MCC&Ponelboords ► �"��' . � i �',��� �i�;+" Dote: . . �0-200 Amp.Under 600 V � . : �...,�_. W - Signa�ure� . . 201-1000 Amp.Under 600 V � ;f:����^���'i:;'1 F- '. Over 1000 Amp.or Over 600 V t �� u� �O Ezempfion for Reg.Maim.Eletl. �. -' ..� . . . � •� r����.�!�i' . . . (i'..�.' . .. .. � � ' � SINGLE FAMILY (� Tem Power Pole&A �'� �,�� l ��.( � � p. pportenonces J 1 ;!; � . � ��� �r � HOME OWNER�BUILDER DECLARATION Sign with One Branch Circuit � �- �'� "����' ' � I heroby affirm thol I om exgmpt from.ihe Conhotfor i License q�ilionol Sign&anch Circuils ' � � low forfhe foilowing reosom(Snction 7031.5;Business and . � � ; Professions Code):.-.. `. . . ,. . � _ - ❑ I,os owner o4'the pr�y,will do the work and�he M!st.Conduits 6 Condoctors , . � . - � � . � � struUure is not ipfended or offered for sale(Section Other(See Comple�e Fee Sthedu�e)_ , � . � � 7044,Business ond�rofessions Code).�.' � � - - ' CONSTRUCTIOR IENDING AGENCY •• . . . I hereby affirm ihat ihere is a mnstrocfian lending agenty for - . . the performonce of Ihe work for which this permil is issued pERMiT FEE � � . � ($ub-Tolol) ��1 i � � - . � (Set.3097.Civ.C.J. - . . . . � � . � PLAN CHECKING FEE , � � � ' � Lender's Name - � � , � � - � � PERMIT ISSUING FEE . . "/�) �l� � � � � �. Lender's Address - - ' � � � � I certify tha�1 have reod ihis opplimtion and s�ate�ho��he TOTAL FEE�� � � , � , above informotion is mrreU.I agree fo mmply wilh oll Cou�y✓""` . � � � � � ordinances and State law"s regulating EleUriml wiring,ond _ � - ' � hereby avtho�ize repres¢nlalives of ihis County 10 enter upon � � � -��� � . Ihe`obove-mentioned propqity fd inspedio�purposes. � � - � � � � 1 f, � �: l , SEE REVERSE FOR EXPLANATORY LANGUAGE '`� 1 ,`. ' ��' .../�. f C-i J f S� '$i�nature bf Permitlee . ', Dale . . . . . . . . . . . . � � . � �. . 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