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Home My Public Portal About5936 HART AVE_Electrical__ WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12-91) PY��®� �� u��D�S�ILe PERMIT . ' LJ I hereby affirm that I have a certificate of consent to self insure, i' ` � or a certificate of Worker's Compensation Insurance;or a certified COUNTY OF LOS ANGELES DEPT.6F PUMIC WORKS BUILDING AND SAFETY DIV. copy thereof(Sec. 3800 Lab.C.) Policy No. Company' FOR APPLICANT TO FILL-IN JOB ADDRESS Certified-copy is`hereby furnished' New Residential Bldgs.&Pools NO. EACH FEE $ $ LOCALITY Certified co Is filed with the count .buildin inspection 1&2-Family,Sq.Ft. ❑',• . � PY Y. 9 P NEAREST department. Multi-family Sq. Ft. CROSS ST. Date r y Applicant Residential Swimming Pools ASSESSOR MAP BOOK PAGE PARCEL CERTIFICATE OF EXEMPTION FROM WORKERS'. OWNER OR r COMPENSATION INSURANCE Outlets:Rec. Light ' Sw• FIRM NAME ,A, 7e First 20 MAIL ' (This section need not be completed if the work involved by the ADDRESS c � Fa�t1Y permit Is,for one hundred dollars($100)or less.) Total No. Additional• 1 certify that in the performance of the work for which this permit CITY Gl?`9I Tel, 3� � is issued, I shall not employ'any person in any manner so as to PLAN CHECK become subject to.the Workers' Compensation Laws. Lighting Fixtures First 20 APPLICANT ' Total No. Additional ADDRESS Date Applicant RESIDENTIAL APPLIANCES NOT OVER.3 HP. NOTICE TO.APPLICANT: If,.after making this Certificate of CITY - Tel.No. Exemption, you should become subject to the Workers'Compensation OTHER-APPLIANCES NOT OVER 3 HP. provisions of the Labor Code, you must forthwith comply with such PERMIT provisions or ihls permit shall be deemed revoked,' Power Apparatus&Large Appliances APPLI.ANT A&-__.1- �� LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS I hereby affirm that'l am licensed under provisions�of Chapter 9 Over 3 to 10 Incl (commencing with Section 7000)bf. Division 3 of the Business and CITY Tel.No. Professions Code,and my license is in full force and effect. Over 10 to 50 Incl. Over 50 to 100 Incl. LICENSE OR Class. REG.NILMBER Over 100 DISTRICT NO. P O ESSED O BY - License Number ! Lic.Class Services,Swbd.,MCC&Panelboards off' U Contracto4—��' "f#2f� �� f 0-399 Amp.Under 600 V on7E/ � O ❑ I am exempt under Sec. 400-1000 Amp.Under 600 V r�f — --1 VALIDATION W Over 1000 Amp.or Over 600 V FINAL B.&P.C.for this reasonBY (n BRANCH CIRCUIT FEES 15A,or 20A,120V,Lighting or Recept. ate: .... 1 To 10 Branch Circuits4'�' °s igna 11 To 40 Branch Circuits. S - ❑ 41 Or More Branch Circuits f o�veak Exemption for R' .Maint.EI ct. 15A,20A,208V To 277V Lighting Br.Circuits _ i "T ( _ L. s ML SINGLE FAMILY Temp.Power Pole&AppurtenancesT.• • 5 HOME OWNER-BUILDER DECLARATION I f I HL ' �-_s I hereby affirm that I am exempt from the Contractor's License_Law 'Sign with One Branch Circuit T for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits CHECK 67.1i . Code): (.!"ttNG . ...: . ... ,CIA ❑ I,,as owner of the property, will do the work and the structure Misc.Conduits&Conductors is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) and Professions Code), CONSTRUCTION LENDING AGENCY 196 i tt t n i 1 hereby affirm that there is a construction lending agency for the Nt Iti , `` performance of the work for which this permit is issued(Sec. 3097, PERMIT FEE (Sub-Total) Civ. C.) 'PLAN CHECKING FEE Lender's Name PERMIT ISSUING FEE Lender's Address " I certify that I have read-this application and under penalty of purjury state TOTAL FEE that the 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 ins/pec�Ion purposes. f SEE REVERSE FOR EXPLANATORY LANGUAGE SIGNATURE OF. RMITT `WORKER'S COMPENSATION DECLARATION 76A669 DPW(12-91) APPLICATION- FOR ELECTRICAL PERMIT [If'LIIIfI •t � " 76A663 �`If �lJ� I hereby affirm.that,I have a certificate of consent to self insure, dr a cer[ificate,of•Worker's Compensation Insurance, or a certified COUNT'Y.OF LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV. cop)ii redo tS7ec. 3800 Lab;C..)) Policy N��/v / � Loin �G �j� FOR APPLICANT TO FILL IN JOB t p ADDRESS ❑ Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. - EACH FEE $` LOCALITY' C✓ C Certified copy is filed with the county uilding inspection 1 &2-Family,Sq.Ft. '` department Multi-family Sq.Ft. cROssssT. (� ate �� '> Pplicant Residential Swimming Pools ASSESSOR �l MAP BOOK PAGE 1PARCEL CERTIFICATE OF EXEMPTI N FA WORKERS' Outlets:Rec..----Light Sw. OWNER COMPENSATION INSURANCE RM NAME (��Pr First 20 (This section.need not be completed if the work involved by the MAIL permit is for one hundred dollars($100)or less.) Total No. Additional certify that in the performance of the work for which this permit CITY %&e , Tel.No. is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws.. Lighting Fixtures• First 20 APPLICANTK Total No. Additional ADDRESS Date Applicant RESIDENTIAL APPLIANCES NOT OVER 3 HP. NOTICE TO APPLICANT:-.If, after making.this Certificate of CITY Tel.No. Exemption,you should become subject to the Workers'Compensation OTHER APPLIANCES NOT OVER 3 HP. - provisions.of the Labor Code, you must forthwith comply with such PERMIT provisions or this permit shall'be deemed revoked. Power Apparatus&Large Appliances APPLICANTCf�. '�C_ /0\L LICENSED CONTRACTORS DECLARATION. Size&Type HP,KW,KVA,or KVAR ADDRESS I hereby affirm that I am licensed under provisions of Chapter 9 Over 3 to 10 Incl. (commencing with Section 7000) of Division 3 of the Business and CITYAv<� Tel.No. • -� �, Professions Code,and my license is in full force and effect. Over 10 to 50 Incl. >, LICENSE OR rj Over 50 t0 100 Incl. REG.NUMBER r L�� . Class. �� O License Number -3-;?_. 3� Lic.Class Over 100 DISTRICT NO. PROC SSED BY U Services,-Swbd.,MCC&Panelboards Contractor�+'��"-+ t� �`°�G Date 0-399 Amp.Under 600'V DATE O ❑ I am exempt under Sec. 400-1000 Amp.Under 600 V b: / VALIDATION W Over 1000 Amp.'or Over 600.V FINAL 01- B.&P.C:for this reason BRANCH CIRCUIT FEES By Date: U) 15A,or 20A, 120V,Lighting or Recept. Z 1 To 10 Branch Circuits Signature 11 To 40 Branch Circuits EJ 41 Or More Branch Circuits -v Exemption for Reg.Maint.Elect. 15A,20A,208V To 277V Lighting Br.Circuits SINGLE FAMILY .... ' a Temp.Power,Pole&Appurtenances �•:~;•E HOME OWNER-BUfLDER DECLARATION Sign with One Branch Circuit - I hereby affirm that I am exempt from the Contractor's License Law =jY ri a i_ for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits Code): 4 ❑ I, as owner of the property,will do the work and the structure Misc.Conduits&ConductorsH-44 _:; ` £i �2 ~: lam, is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) T._ :.-. r _ ... -ii and Professions Code). t; Y4.f; 1Yt CONSTRUCTION LENDING AGENCY (t, Iaii DID I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total) Civ.C.) PLAN CHECKING FEE ?,i;`tiL Lender's Name PERMIT ISSUING FEE Lender's Address I certify that I have read this application and under penalty of purjury state TOTAL FEE that the 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 inspectio, purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE SIGNATUR OF PE ITTEE DATE