HomeMy WebLinkAbout11_19_1984 - 21073 PATHFINDER RD WORKERS'COMPENSATION DECLARATION a. 76A663 10/el � �
1 heraby affirm that I hava a certificote o�consent to�F�E.� APPLICATION FOR ELECTRICAL PERMIT
insvre,or a certifica�e of Workers'Compensation Insurance, COUNTY OF LOS ANGELES � BUILDING AND SAFETY
. or a certiiied copy thereof(Sec.3800,LLob`.C.) �'J �
P❑olicy No �O �pmpa�Y J(.I rb� y�l/,4f�/ FOR APPtKAM TO FILt IN DDRESS�� � /� I N �
Cerfified copy is hereby furnished. New Residentiol Bldgs.6 Pools EACH nq. PEE
� Cerfified[opy is filed wilh ihe county building i - � 1 8 2-Family,Sq.Ft. f — E LOCAUTY '
fion deparlmenL Molti-family Sq.FI. — �A�ST .. .
Residenlial5wimming Pbols CROSSST.
Da1e/�Applicant OWNER OR ��
f� �j FIRM NAME
CERTIFICATE OF EXEMPTION FR WORKERS"� Ourlets RecL�Light�5w.[L ♦ � '�'A�� ' �
� � COMPENSATION INSURANCE- - '��' - First 20 J ADDRESS
(Th�s s«tton nwd nor ba compl�isd if 1he work Invoivod by Total No.� Additionol � CIN Tel.No.
tha pe�mft Is for one hundr�d dollan(5100)or less.)
- I certify�hat in tha performance of the work for which this . , . � ' qvpNjGqNTK � ' �
permit is issued,I shell no�empioy any person in any manner r .
- so as to become subject�o the Workers'Compensation laws. Lighting Fixiur'es/� First 20 S S� AODRESS . � —
. . . .' . Total No.� Additional � , .
Date oppiicanl '• � , CITY Tel.No. �
NOTICE TO APPLICANT:�If, oNer moking �his Certificate of� F�xed Applionces Nol Over 1 HP PERMit 1
Exemption, you should become subject to tha Workeri Range_Heater_D.W.�_ AaPI�CP'NT^`'S �� "
Compensalion provisions of the Lobor Code,you must(orth- Oven _Dryer _W:M.— ADDRE55 S�
with comply with such provisions or this perm(f sholl be Top _FAU —W.H.—
deemed revoked. ' Hood _Fan _Olher_ � CITY A�( Tel.No. �i -
� LICENSED CONTRACTORS DECLARATION LICENSE OR
�isp. _Room Air Cond. — Closs. � •
I here6y affirm fhai I am licensed under provisions of Chapter 9 . . REG.NUMBER 3 7 � � �
(commencing with Section 7000)of Division 3 of the Business DISTRICT NO F ESSED BY �
ond Professions Code,and my license is in full force and effect.� Power Apparotus&large Appiiantes � }
G� �y Size 8 Type HP,KW,KVA,or KVAR- �
_ license Number��/ �7 v lic Closs C� .. ' Up to 1 Incl. F1NAL� . . O —
CoMrat�or��S k E'�r-c Dote �l"��f��y � Over 1 to 10 Ind. DATE /��?�8� . VALlOATION �
O � Over 10 10 50 Ind. ►- .
FINAL
I am exempt under Sec. � Over 50 to 100 Inc. BY W
B.&P.C.for this reason —� Over 100 � � y ,
- - Dale: . . Servicas,$wbd.,MCC 8 Pa�elboards� : .. . . ' ..`���.9-r' _ .--
0-2W Amp.Under 600 V � . � � �e • . . � 9 " .
Signature � 201-1000 Amp.Under 600 V � � � . - � � -
❑ Over 1000 Amp.or Over 60p V � •��� 5�.?� '
Exemption for Reg.Maint.Elect.
_ SINGLE FAMILY Temp.-Power Pole&Appurfenances � � ' ° � ���'-' . �
� HOME OWNER-BUILDER DECLARATION Sign with One Bronch Cirwit • �
I hereby affirm ihat I om ezemPl fiom�he Conhactor's Licanse � � 2� —?(�.
Law for the following reoson(Section 7031.5, Business ond � Addd'°^°�Sign Branch Circ�its � . _ �,
Professions Code): . � � � A �
� � � � Misc.Conduils 8 Conductors � . - ��+�i'��l N_ .
I,as owner of ihe property,will do Ihe work ond the • -
51ruUure is nof inlended or offered for sole(Saction Olher($ee Complele Fee Schedule�_ � �.`3� ��Q Q
7044,8usiness and Professions Code). � •3 1 1.0 0� � .
CONSTRUCTION LENDING AGENCY -� � ' � .
I heraby offirm thc�there is o constroction lending ogenty for - ` . .� , 0�?2�5�—g.5 . . .
the performance of�he work for which ihis permit is issved- PERMIT FEE � � � (Sub-Totol) ��� ,$��' - . .
(Sec.3097,Civ.C.). � . - .
� � PLAN CHECKING fEE " � s' � . . . ...
lender's Nome , PERMIT ISSU�NG FEE
Lender's Address � � � ' � j/�
I certify thot I hove reod this o � io tion and s�afe tha�the TOTAL FEE � - 1� ' " �
above informolion is torrect.I o ee 1 comply with all Counly . � .
ordi ces ond Sto1e laws re ulati g tiricol wving,and � � , � .
he aothorize representati es of h' ounty lo anter upon - . . � � . � _ , j/ � ��
t ove-mentioned rope y fo m Uion purpases. i
SEE REVERSE FOR EXPIANATORV IANGUAGE �
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