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HomeMy WebLinkAbout02_12_1987 - 21015 PATHFINDER RD (2) WORKERS'COMPENSATIONDECIARATION �6a667 ,o�e� APPLICATION FOR ELECTRICAL PERMIT � I hereby offirm tha�I have a certificate of consent to self CE-806G insu�e,or a ce���fcme of Wo�ke�s'Compenso�ion I�suronce, COUNTY OF LOS ANGElES BUILDING AND SAFETY or o certified copy there�o/l(Sec.3B00,Lob.C.) i . P�olicy NofG�L��(J�Spmpony �/.<�/'�� FOR APtIICANT TO Flll It1 JOB Cerfi(ied[opy is hereby furnished. New Rasidential Bldgs.8 Pools EAGH NO. FEE ADDRE55 �f5 Jr T ` � � 1 8 2-Pamil q. LOCALITY � Certified copy is filed with rhe munt building' pe y,S Ft. S — S �p tion depoitmenl. � Multi-family Sq.FI. — NEAREST �_ � Resideniial Swimming Pools OWNER OR / DaleL%� `p7 Applita , FIRM NAME /�G/f/G . �� p� � CERTIFICATE OF EXEMPT N FR M RKERS' � ,��/ � �' Hv+a " Outle�s:Rec Light�Sw. A�DRESS fJ?�G/�LL Y / � � � '- COMPENSATION INSU CE First 20 �`� �� � "(Thit�ectio�n��d nof bs eompl�}�If fhs work i�rolved by To�ol No.� Addi�ional CITY ��,� Te�.No. tM permif 1�for one hund�ad dollars(SIOD)or lass.) � I cerli(y thot in the performance of the�work for which this . �C qp�(;qNrK � / �permit is issued,I sholl nof employ any person in any manner J — — so ai fo bacome subject to Ihe Workers'Compenwfion Lows. LigMing Fiztures j� First 20 / ADDRESS �� .GD��� ti � � - Addilionol � � . Total No. GTY ��f Tel.No. ' Dote 4pplicaN Fixed Appliontes No1 Over 1 HP pERMii i � /� /� NOTICE TO APPLICANT: It, after moking this Certificote of APPtiCANT �[. L�l C..1.�5, Eaemption, you should become subject to the�Worken' Range_Neoter_D.W._ .. Compensation provisions of the la6or Code,yov must forlh- Oven _Dryer _W.M._ , . , ADDRESSt`� .w �wirh mmply with such provisions or �his�permit shall be Top _FAU —`1V.H.— deemed revoked. . � CITY ��,y h.j i. �o. �F-�y�- �v . LICENSED CONTRACTORS DECLARATION Hood _Fan _Other_ ' � � Disp. _Room Air Cond. _ ���EN�� � Clau. �hereby aHirm�hat I am I�tensed onder pravisions of Chapter 9 REG.NUMBER Y� �(commencing with Sedion 7000)of Division 3 of the Boeiness power Apporatus 8 Large Applionces DISTRICT NO. BY 0: and Professions Code,and my license is in full forte and eHed. � `. . }� / Size 8 Type HP,KW.KVA,ar KVAR' 1--. License Nomber�€7�'b lic,Goss� FINAI � JN'd��;�s� Up to 1 Incl. / �����// ��y Over 1 to 10 Ind. DATE ����C VAl1DAT10N � . Contratto���_ Date�� f Over 10�0 50 Incl. V ❑ � FINAL Lel I am exemp�under Sea Over 50�o I00 Int. 8Y Lr� � � 6.8P.C.for Ihis raoson Over 100 ��� z .. _ .. - „ Servites,Swbd.,MCC&Ponelbaards � ' O-200 Amp.Under 60D V ' $ignature �� 201-1000 Amp.Under b00 V �OOver 1000 Amp.or Over 600 V Ezempti or R .Maint.E u. �3 5 1,a a SINGLE FAMILY Temp.Power Pole 8 Appurlenances � #. : •�•2 HOME OWNER-BUIIDER DECLARATION ${9n with One Bronch Circuil I�� �'''&'.�5 I hereby efiirm that�om exempt from the Contractor's License Additional Slgn Branch Cirwiis � � Law for the following reoson(Sedion 7031.5, Business ond - ►'• •1 �7 Jr� Professions Code): , . . ❑ I,os owner of rha property,will do the work and the Nisc.Conduiis 8 Conducbrs �2� 3_a 7 strucWre is not iMended or oNered for sale(Settion Olher(See Complete Fee Schedule)— � - - � � 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY • � � � I hereby a(firm�hat ihere is a consKuUion lendin9 agency for � the performance of the work for which�his permil is issued pERMIT FEE � � (Sub•To�al) � - (Set.3097,Civ.C.). . PIAN CHECKING FEE" � � � lender's Name . PERMIT 155UING FEE U � Lender's Address /a � . � I certify thot I hove read�his applitalion ond sto�e thof the iOTAL FEE p - above informarion is mrrect.I agree ro comply with ail Coun�y ordinances and Stote lows re laii Electrical wiring,and � . , . . hereby aulha�ize tepresenl es this Counly to ente�upon the a6ove-menY ned pr �ry inspedion porposes. - , SEE REVERSE FOR EXPLANATORY LANGUAGE a reof �n-inee Date . � � � � , . � . , _ � ' f� ' . ' � t ��,� ' i . � ��.-. �� � �� �'� �� . ' Srf 1 . ,� � �t 4` �` . r f� 1 :{ � � � . �•� � �! - , � ,.✓' , ' � .. ,. ., � e ���� 'z , . � � ' � . ` . .. C � � .�� �'� �. '� -�, �� �� �� � 1� '� � ,� `w % ' � � .� O '� � � � � . � Z ' � �. y. � N. -o. Y Q p �� � m n" C� � � � ,. 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