HomeMy WebLinkAbout04_25_1985 - 21073 PATHFINDER RD WORKERS'COMPENSATIDN DECLARATION ' 76A663 �o,e, _ APPLICATION FOR ELECTRICAL PERMIT� �
I here6y affirm that I have a cerfificote of mnseM to�self �E'� . �� �I
Insure,ar a rertifim�e of Workers'Compensation Insvrance, COUNTY OF LOS ANGELES BUILDING AND SAPETY /J
.or a certified copy the�eof(Sec.3800,Lab.C.). . � � .
�7 LJ
POol�ity Noc-fc$�/09 Company6�TA��,�(JtU D FOR A►PLIGM TO FILL IN _ ��B 1 �7-�� /� fG� �.
Certified copy is hereby fomished. New Residential Bldgs.8 Pools EACH NO. FEE ADDRE55 �1� /Q 1 Pl(' N�K
1 8 2-Famil� FI. E — E LOCALITY b 1••.�OM Q �
�Certified copy is tiled with the tounfy building inspeo- Y.S9� _ ,
fion depar}men1. � � Mol�i-fomily5q.Ft. NEAREST ,c`U
� y� Residenliol Swimming PoolS OW ER OR ''
Date�n�TApplicant� . . .
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKER5 � � - �� � � � ��� rn.au '
COMPENSATION INSURANCE �� , Outlets:Rac Light 2 Sw. ,., qppRESS
This secilon need no1 bs com la}ad it tha work inrolved b J''�Q Firsl 20 �~ , .
� P Y Toial No./�L�,( Addi�ionol a CIN � I.No.
th�p�rmit is for on�hundred dellars(SI00)or I�ss.) '� . -
I certify that in the performance of the work for which this / � APPLICANTK � .
_ permit is issued,1 sholl noi employ any person in any manner —
so os to betome subjetl to the Worke�s'Compensolion laws. Lighling Fiarures Fint 20 � ZC ^ AODRE55
. � . . . �. � .. � . Tofol No.�_ Addirional .. .
CITY Tel.No.
Daie epplimM Fixed Appliantes Not Over 1 HP . pEw�ii f' �/
NOTICE TO APPLICANT: If, offer moking this Cerfifica�e of � APPLIGAM � 1� ��--(-�C I�/ ` �
Ezemp�ion, you should betome sobjecl 10-Ihe Workers' Range_Heater_D.W.— � �
Campensolion provisions of the lobor Code,you must forth- Oven —Dryer _W.M.— � ADDRES$ � S� ��)� g� ��
with comply with wch provisions or.rhis permit sholl be 7op _FAU —W.H.—� � ,
deemed re�oked. - - �. Hood _Fan �_Other_� CITY S �-�.Ay Tel.No.
� LICENSED CONTRACTORS DECLARATION � ��Q�
I hereby affirm thot I am licensed under provisions of Chapter 9 Disp. _Room Air Cond. — R GN UB ER [ 7 r-' �� C ass.Q /C �
(commencing with$ection 7000)of Division 3 of Ihe Business power Apporofus&Lorge Appliantes DISTRICT NO._ � . PROCE BY 6 '
and Rofessions Code,and my license is in full force and effect. /1, � �
� Size 8 Type HP,KW,KVA,or KVAR� d Q �
- license Number'37g��o � �,�.��o„ � I� � FINAL ' � V —
. Up to 1 Incl. � DATE - �
�tsk �'LCrC Do�e ������D � Over 1 to IOlncl. ¢y VALIDATION Q �
. Conlraclo Ovar 10 to 50 IncL �
❑ FINAL U
I am exempi under Set. Over 50 fo 100 Inc. BY �++
6.
B.BP.C.for this reason � Over 100 . . . � ,
Sarvices,Swbd.,MCC 8 Panelboards � � � - - Z
- . Date: 0-200 Amp.Under 600 V L ��JJ . .-
Signoture � � 201-1000 Amp.Under 600 V � . 7�T`�,�?,�./1/.l �.n�� . .
O �Over 1000 AmP.or Over 60p V //A ��{'�v „ . . . . .
E x e m p l i o n f o r R e g.M a i n l.E l e c t. �br• �j�
SINGLE FAMILY � � r+•(y,V•,
Temp.Power Pole 8 Appurtenances / . .
HOME OWNER-BUILDER DECLARATION �}.� i
Sign wilh One Bronch Circuit �� � -
I hereby ai(irm Ihat I am exempt from 1he Controctor's License Addilional Sign Branth Cirtvils �, ../
Law for the foliowing reason(Section 703I.5, Business and �� /�< . � �
ProfessionsCode): - � � � OV � �
❑ I,os owner of the properfy,will do the work and fhe �Misc Conduits 8 Conducrors - � � � -
sfrudure is nor intended or offered for sole(Sedion. Other(See Complete Fee Schedule�_ ,
7044,Business and P�oiessions GodeJ: � . �lG C:7.7 A
CONSTRUCTION LENDING AGENCY � � ' jf• • • •Z ��
� 1 hereby offirm thot there is a construdion landing agenry for � �� •� ' - �
the performonte of the work for which this permit is issued pERMIT FEE � � � (Svb-Totol� t�l - � •-��� �,J�� ' ,
(Sec.3097.Civ.C.). � � , .
� . � . � PLAN CHECKWG fEE � � � � ° ��'� �.L^�.O c=a ��
Lender's Name � PERMIT ISSUING FEE . �� �h 2 J�-8 J� � �.
� lender's Address . � j t r t� �
I certify that I have read this applicoFlon and s�ate that the TOTAI FEE � o �
above informa�ion is corced.I a9ree ro mmply with oll Counry� � , . '
ordinontes and Stafe lows reguloting Electriml wiring,and . . � . . :
hereby authorize representatives af this Counry to enter upon . . � - � " � �
the e-m ' ned pro erty far inspedian purposes. � � .
, Y�2s=8�"
SEE REVERSE FOR EXPLANATORY tANGUAGE
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