HomeMy Public PortalAbout5824 HART AVE_Electrical__ WORKERS'COMPENSATION DECLARATION
CE-806 �, PP UC�Q��Oo N FOR ELEC YMC AL PERMa
� CE-806G (2-80) _
I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY
insure, or a certificate of Workers'Compensation Insurance,or
���jye tifr'P� c��}�gt er of(Sec. 3800,Lab.C.)
7 l JvY IdGOFOR APPLICANT TO FILL IN JOB
Policy No. ne e
Company EACH NO. FEE ADDRESS 5824 Hart
of the est. New Residential Bldgs.&Pools
Certified copy is hereby furnished. 1 &2-Family,Sq. Ft. $ — $ LOCALITY Te
Multi-family Sq. Ft. } — NEAREST
Certified copy is filed with the county building inspection CROSS ST Las Tun;aq
department. Residential Swimming Pools OWNER OR
11-6-81 Edwards Electric FIRM NAME `
Date Applicant Outlets: Rec._Light_Sw. MAIL
First 20 1ADDRESS
CERTIFICATE OF EXEMPTION FROM WORKERS; Total No. Additional CITY Tel No.
COMPENSATION INSURANCE }
PLAN CHECK 0
APPLICANT
(This section need not be completed_if the work involved LiFixtures First 20 U
Lighting ures s
by the permit is for one hundred dollars ($100) or less.) ADDRESS
Additional
Total No.
I certify that in ,the performance of the work for which this Fixed Appliances Not Over VHP CITY Tel No. 0
permit.is issued, I shall not employ any person in any manner PERMIT, LU
so as to become subject'to the Workers' Compensation Laws. Range_ Heater_D.W. APPLICANT Edwards Electric tl to
Oven Dryer_W.M. ADDRESS 2535 S. 3rd A e z
Top _ FAU _W.H.._
Date Applicant CITY Arcadia Tel No. 447-5096
Hood — Fan _Other
NOTICE TO APP LICANT:•If, after making this Certificate of Disp. _ Room Air Cond._ LICENSE OR
Exemption, you should become subject to the Workers' REG.NUMBER Class
Compensation provisions of the Labor Code, you must forth- Power Apparatus& Large Appliances DISTRICT NO. PROCESSED BY
with comply with such -provisions or this permit shall be Size&Type HP, KW,KVA,or KVAR
Q
deemed revoked.
• � ' Up to 1 Incl: FINA. '
Over 1 to 10 Incl. DATE VALIDATION
LICENSED CONTRACTORS DECLARATION VAL'I DATION
Over 10 to 50 Incl.
I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. FINAL
Y AL
9 (commencing with Section 7000) of Division 3 of the Busi- Over 100 '
ness and Professions.Code, and my license is in full force and
effect. Services
License Number '257191 Lic.Class C-10 0-200 Amp. Under-600 V
Edwards Elect�it� Ju 1982 201-1000 Amp. under
Contractor a Over 1000 Amp.or Overr 600
V
HOMEOWNER=BUILDER DECLARATION Temp. Power Pole&Appurtenances
I hereby affirm that I am exempt from the Contractor's Sign with One Branch Circuit
License Law for the following reason (Section 7031.5, Busi- Additional Sign.Branch Circuits /� ]�( 4 A
ness and Professions Code): # o 0 0`0 0.2.
Misc.Conduits&Conductors ,
I, as owner of thetproperty, will do the work and the Other (See Complete Fee Scheduler
structure is not intended or offered for sale (Section o:o,o.0 0 0 o2
z
1.
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY 0 4h_1 A T 8,1
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is PERMIT FEE (Sub-Total)
issued (Sec. 3097,Civ.C.).
Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee)
Lender's Address PERMIT ISSUING FEE
A certify that I have read this application and state that the TOTAL FEE
No Fe-c-
above information is correct.I agree to comply with all County
ordinances and State laws regulating Electrical wiring, and
hereby authorize representatives of this County to enter upon
the above-mentioned property for inspection purposes. SEE'REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date