HomeMy WebLinkAbout11_19_1984 - 21015 PATHFINDER RD WORKERS'COMPENSATIONDECLARATION � � ��3 ,o�B, qpp��CATION FOR ELECTRICAL PERMIT � �;
I hereby affirm fhaf I hove a cerlificote of consant fo self ��C . .
�nsure,or a cerefimte oi Workari Compenwtion insu�onc�� COUNTY OF LO$ANGELES BUILDING AND SAFETY
or a certifi�e7d,copy thereo6f�Set.3800,Lob.C. � � � . � �
�o���d 7 1
Policy No. Compony �FOR APPLIGM 70 FlLL IN JOB � �
� Cerfi(ied copy is hereby furnished. I New Residentiol Bldgs.8 Pools FACH NO. FEE /•DokE55
� � 1 8 2-Famil FI. , f — = LOCAUTY �,
Cartified topy is filed with the counry boilding insp - Y.S9•
tion deporlmenL Mul�i-family$q.Ft. — NEAREST :
/� �� (�� Residentiol Swimming Pools CRO55 ST.
Da�e�ApPlicant OWNER OR
/ FI17M NAME
� CERTIFICAiE OF EXEMPiION F WORKERS' �J � � � - MA�I �
Ou�leti:Rec_lighf Sw qDDae55
� COMPENSATION INSURANCE ��JS aO I 1�} � � -
Thfs fett�on nesd�nm bs eom lafed if tha work inwlved b . Fiist 20 ,
� P Y To�ol No.� qddirional 6 Q CITY � Tel.No. '
ths permft is for ons hundrod dollms(SI00)or laa J � ptAN cr�cK
I certify that'n�he performance of tfie work for which this - ^ i qpp���t �L,eeTrL .
permil is issued,I sholl not employ ony person in ony manner � —
— so as to become subjett fo ihe Workers'Compensation Laws. ligh�ing Fiztu�es First 20 'y � � ADDRESS3 S• /�
yn Additional � /
� � - Total No.� CITY� A.Tel.No. 5 � �
Dote a.Tplicont - Fixed Applionces Not Ovar 1 HP pERMIT f '
NOTICE TO APPLICANT: If, aNer moking this Certificate of APPLICANT ��sS ���� C � "
Eaemption, yoo should�betome subject to the Workeri' Range_Heoter_�.W._ �
Compensotion provisions of the labor Code,you mus�forth- Ovan _Dryer _W.M. . ADDRE55 ,
with Comply with suth provis(ons or this permit shall be Top _FAU —W.H.� . .
deemed revoked. � � � Hood�_Fan _Other_ � CIN � � Te�.No. . ,
� IICENSED CONTRACTORS DECLARATION .�� � �. uCENSE OR
I hereby effirm lhat I om licensed undar provisions of ChapM 9� Disp. —Room Ai�COnd. — REG.NUMBER� 7 Q Clpss,y � '
(commencing with Section 7000)of Division 3 of ihe Business power Apporatus 8 Larqe Appliantes . � DISTRICT NO.� PR D BY ,
and Protessions Code,and my license is in full force ond effect. . � - �1�,�� p}, .
G C/� Size 8 TYpe HP,KW,KVA,or KVAR� �/ ` b�/L��� � �
License Number ��7�7� Lic.Closs �� � Up to 1 IncL � -7�Bd / FINAI � - � - �V �
N.s/L� /�6� Date�� ..�— �er 1 to 101nd. DATE r !,� VAIiDATION � .
Contrat�or O Over 10 to 50 Ind. �l - O .
� D FINAL . . . . . . ,
I om e�empt under Sec. � Over 50 ta 100 Inc. BY a
B.BP.C.fot Ihis reason a'e`'�� -�B-S II.O A� Z �
. ��e: - � Services.Sw6d..MCC 8 Ponelboards - . ... •. .
.. • 0�-200 Amp.Undar 600 V ' e ���• • } C) . .
Signature �'101-1000 Amp.Under 600 V " � � - �
D , Over 1000 AmO.or Over 600 V 0 .. . . �.!G J 7,7 Jr - �
Exemp�ion Por Reg.Mainl.EIeU. � � �q
� •����G'�'�ty'O��
� SINGLE FAMILY - - Temp.Power Pole 8 Appurtanancas ' t - �
� HOME OWNER-BUIIDER DECLARATION � � - ��r;�����S�� �
Siqn wilh One Bronch Cirwit
I hereby affirm that I om erempt from ihe Contractor's License � � � ' p r
Law for the following reasoo($edion 7031.5,Bosiness and +4dditionol Sign Bronch Circuits � � �.•�l..�i�� -
Professions Code): _ � � . .°�!���Z n�u . �
❑ 1,as owner of the ro er 11 do the work and fhe �� M,st.Conduits&Condutlors � � �� �• • - ��
� P P ty'W� O�her See Com lete Fee Schedule_ � G Z G FJ—a J�
siructure is not infendad or offered for mle�Secfion . � P ) , . _�
7044,Business and Professions Code). . ��IG S
CONSTRUCTION LENDING AGENCY � , � -� -� � - � �
I hereby aHirm ihol ihere is a construclion lending agency for ',
� the performance of ihe work for which this permit is issoed PERMIT FEE (Sub-Totol) � �- � - �
� (Sec.3097.Civ.C.). �� yF` 0� . �
PtAN CHECKING FEE � . 37 � , � . . .
lender's Name I . �
' PERMIT ISSUING PEE . I .
Lender's Address - � � - � j
I cerfify thot I have read rhis oppi' ion and state ihot the . TOTAI fEE � 702-3 � - �
above informo�ion is mrrect.I agr e t mmply with oll County . ' �
or ancee ond S�ote laws re oti ctrical wiring,and - . � �
er y authorize repre Nati s �hi ounly to enler opon � . ' � ( - � - � . .
Ih ab -meMioned ope i ction porposes. � � 1. ., .
//'/�+ �� SEE REYERSE FOR EXPLANATORY LANGUAGE ,
7
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