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04_22_1987 - 21073 PATHFINDER RD
WOF�ERS'COMPENSATIONOECLARATIO�- �6A663 � APPLI�ATION FOR ELECTRK�AL PERMIT �1 , CE�806G(2-80) �t 1 hereby a� ln that I hal�e a cereflcate ot consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY U insure,or u-certificate ot Workers'Comprnsation Insurence,or � , - a certiPied copy the�y�of Sec.3800,Lab.C.) ' � - � �y av"(��jJ FOR APPLICANT TO FILL IN JOB L1 I` Pollcy No.L�tl�ompany � � � EACH NO. FEE ADORE � O�� I!`}�/!F�Nv� � New Residential Btdgs.&Pools n � C ifled copy 1s hereAy furnlshed. 1&2•Family,Sq.Ft. $ = a LOCALITY � (�� rn 6 � � /�- Multi•family Sq.Ft. Certified copy is filed with th ounty ' ingj ction CROSS ST � department . Residential Swimming Pools . , OWNER OR• '��.� I^ ���'(_�J 2 C � .` FIRM NAME'.� I i"! Date a/Applicant Outlets:Red�Light�Sw./� � 1J � ADDRESS'���- /// - J � � � � First 20 CERTII'ICATE OF EXEMPT[ON FROM WORKERS' � Total No,� Additional - CITY ��� Tel No. - � . COMPENSATION INSURANCE� � , PLAN CMECK O}. APPLICANT O — Clhia section need not be completed it the work involved �7� U — by the permit is for one hundrtd doltazs(f100)or less.) . Lighting Fixtu es First 20 qo�REss _ . � � � Total No.� Additional � . � 1 certity that�in the peitormance ot the work tor which this � Fixed Appliances Not Over 1 HP CI7Y �.�; . Tel No. � permit is issued,I shall not cmploy any person in any manner . � vERMIT �^/ D W - so as to become subject to ihe Workers'Compensation Laws. Range_H¢ater D.W._ APPLICANT���c.S I�f/�C� C-1 a � � � � � Oven _Dryer_W.M,_ . � . ADORESS:��J/ s•rn A i ry � � Z � Date Applicant ' Top _FAU -_W.H�..� . , . CI7v�j ' Tal No. �/ � Hood_�Fan _Other_ NOTICE TO APPLICANT:i[.after making this Certiflcate.of Disp. _Room Air Cond._ LICENSE ,�i��: .�C ; Fxemption, you should become subk« to the Workers' . . REG.NUMBEFi� lass Compensation provisions oi the Lebor Code,you must forth- power Apparetus&Latge Appliances � DISTRICT NO-.-- � PROCESSED ev � ; with comply wiih such�provisions or this permit shalt be - deemed revnked. � , Site&Type HP,KW,KVA,or KVA '.�` _ � - Uptollntl. FINAL � — � Over 1 to 10 IncL � � DATE - � LICENSED WNTRACTORS DECLARATION � Over 10 to 50 IncL � �VALIDATION . 1 hereby aftirm that 1 am�icensed under provisions of Chapter Over 50 to 100 Ine. FiNA 9 commencin with Section 7000 of Division 3 of the Busi• BY �� ( B ) Over 100 �-�� - .y�,.v G i � � ness and Rnfessions.Code,and my license is in full force and . . ; � effect. - 'f Serviees � � � ' License Number��� ��V Lic.Ctau G�� � �-200 Amp.Under 600 V - � . � $;� ���. .�� 1� ^7 201-1000 Amp.Under 600 V� � Contractor'��� ��'EC• Date �Y �2 ��/ Over 1000 AmP.or Over 600 V . � ° " ��S'(�i � , HOME OWNER-BUILDER DECLARATION - Temp.Power Pole&Appurtenances � � - - " ' � `�" � � Sign with One Branch Circuit � �;� ��_:j 7 t hereAy atfirm that 1 am exempt from the Contractor's qdditional Sign Branch Circuits � � � � �License Law(or[he following reason (Section 703L5,Busi• � � � ness anJ Rofessions Code): � � . � � Misc.Conduits&Conductors . - � - � I,as ownet of ihe property,will do the work and�he p�her(See Complete Fee Schedulel— - � � - structuro is not intended or offered tor sale (Sectian . � , 7044,Business and Pmfessions Cnde). � • . . ' - � CONSTRUCTION LLNDING A(?ENCY � � I hereby af(irm Ihat ihere is a construction iending agency � ' ' � :, � � � for the performance of the wark for wMch this permit is pERMIT FEE � � (Sub-Tota11 � � tssued(5ec.3097,Civ.C.). � ,. ' � - ' LendePs Name � PLAN CHECKING FEE (One•Fourth Permit Fee) - � LendePs Address � PERMIT ISSUING FEE . . � ,7 � � , i certify that 1 have ad this a Iicallon and state that the TOTAL FEE . . Q � . � above intormation i. orr cL I e to comply with all County ' - � ordin s and te aws lating ElectAcal widng, and � . - � � � . � � , her authori re�esent i s of this County to enter upon � � /1 t ve-me n Ed pro for inapection purposes. � SEE'REVERSE FOR EXPLANATORY LANGUAGL / y��"�� / igna[ure of Permittee . Date � � , . �, I_ � ' � � � � . . � ` � I--- �-�; ._1 . ',.�.,.._.'. : _ ` . ; 4_. . t � � ;-. Q, � ! , � � � � � �� " � I � I " '. ; � - , � � i � 1 /., j ' - I ! I - � ! ,-^1� _ � i i , _- - � .%, _ y�=1 � .�� � _ I � - • �` a• .. . ��y� � , ' lv . 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