The URL can be used to link to this page

Home My Public Portal About6011 HART AVE_Electrical__ a WORKERS'COMPENSATION DECLARATION CE-806G 10/81 y�PP �/� AT7 O,N 'FOR ELECTR�(�/n�,p P(e RM1 T I'eeby affirm that I'have a certificate of consent to self insure, CE-ao6G GsUIf�IP`L� leo II II�1 Ir �/ti�L� L� IICNII '.. or a certificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY Iu' copy thereof(Sec.3800,Lab. C:) Policy No.�/Ac. /qC6mpany.//e—GeLL #1W✓ FOR.APPLICANT TO FILL IN JOB - � ❑ Certified copy is hereby furnished. New Residential Bldgs.& Pools EACH NO:. FEE ADDRESS iry Certified copy is filed•with-the county building inspection 1 & 2-Family,Sq.Ft. $ — $ LOCALITY G� department. Multi-family Sq.Ft. CROSS ST. NEAREST _ n I � Dated`'.ll'rer 'Applicant 1� �i"✓�/V AZA3G1 Residential Swimming Pools OWNER OR ,. •FIRM.NAME U 1.,•, CERTIFICATE OF EXEMPTION FROM WORKERS' MAIL - COMPENSATION INSURANCE Outlets:Rec— Light Sw. ADDRESS This section need not be com leted if the work involved ti the First 20 " (. P Y CITY+ Tel.N ,permit is for,one hundred dollars($100)or less.) Total No. Additional I certify.that,in the performance of the work.for which this permit - PLAN CHECK Y P - APPLICANT is,issued, I shall not employ any.person in any manner so as to, D, become subject to the:Workers'Compensation Laws. Lighting Fixtures First.20 ADDRESS Additional Total No. -•CITY• Tel.No. " Date Applicant Fixed Appliances Not Over 1 HP PERMIT NOTICE TO APPLICANT: If, after. making this Certificate of APPLICANT Exemp _tion„you should become subject-to the Workers'Compensation Range_ HeaterD.W. / provisions of the Labor,Code,-you must:forthwith comply with such Oven Dryer'_ W.M.— ADDRESS'/ U �', d�1T ILA-, provisions or this permit 'shall be deemed revoked. Top FAU W.H, CITY , Tel. _ LICENSED CONTRACTORS DECLARATION •Hood — Fan Other I hereby affirm that•I am licensed under provisions-of Chapter 9Disp. — Room Air Cond. :4 LICENSE OR (commencing with Section 7000) of'Division3 of the'Business'and REG.NUMBER Class. Q .Z Professions Code,and my license is in full force and effect. Power Apparatus&Large Appliances DISTRICT NO, .' PROCESSE Y a _ Size& Type HP,KW,KVA,or KVAR O License NumberyLia Class 0, `�� p to_1 Incl: '•. FINAL ,L U CS"6ver r,1 to 10 Incl. i dDATE � VALIDATION Contractor940,YQyL&�C/I '14�Q� .10 to 50 Incl:' 0 FINAL, U ❑ I am exempt under Sec. Over 50 to 100 Inc. BY / W B.&P.C.for this reason Over 100 1D. Services,Swbd.,MCC& Panelboards D N --Da te0-200 Amp.Under 600 V Signature 201-- 1000 Amp.Under 600 V Over 1000 Amp.or.Over 600 V Exemption for Reg.Maiht.Elect. SINGLE FAMILY Temp.Power Pole,& Appurtenances 9 9.1.&1 A HOME OWNER-BUILDER DECLARATION Sign,with One,Branch Circuit 1 hereby affirm that I am exempt from the Contractor's License Law # 0,6,0 o.0 2 for the following reason(Section 7031.5, Business and Professions ,Additional Sign-Branch Circuits Code): Misc.Conduits &Conductors o- 0 0 0 ❑ I,as owner of the property,will•do the work and the structure 21.0 is not intended or offered for sale.(Section 7044, Business Other(See Complete Fee Schedule) D and Professions Code). O 6 1'$8 CONSTRUCTION LENDING AGENCY 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.)s PLAN.CHECKING FEE` Lender's Name PERMIT ISSUING FEE Lender's Address I certify that I have read this application and state that the above TOTAL FEE 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 WORKERS' COMPENSATION DECLARATION CE-806 ,O,B, APPUC�A HON FOR C�dL�C��' UC AL p[�G�MT I he°reby affirm that have a certificate of consent to self CE-806G insure, or a certificate of Workers' Compensation Insurance, ' COUNTY OF LOS ANGELES BUILDING AND SAFETY or a certified copy thereof (Sec. 3800, Lab. C.) Policy No. Company FOR APPLICANT TO FILL IN JOB Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADDRESS r t ❑ 1 & 2-Famil $ $. LOCALITY Certified copy is filed with the county building inspec- y, Sq. Ft. e--i^ E tion department. Multi-family Sq. Ft. — NEAREST, :(, 9 Residential Swimming Pools CROSS ST. Date Applicant OWNER OR CERTIFICATE OF EXEMPTION FROM WORKERS' MAIL Outlets: Rec Light Sw._ COMPENSATION INSURANCE ADDRESS completed if the work involved b First 20 (This section need not be com p Y Total No. Additional CITY • Tel. No. the permit is for one hundred dollars($100)or less.) Cs IC PLAN CHECK I certify that in the performance of the work for which this APPLICANT permit is issued, I shall not employ any person in any manner so as to become subject to the Workers'Co sation ws. Lighting Fixtures First 20 ADDRESS Additional Total No. -CITY Tel. No. Date G Appli:a Fixed Appliances Not Over 1 HP PERMIT NOTIC TO PPLICANT: If, after making th s Certificate of APPLICANT e F d E f )C Exemption, you should become subject to the Workers' Range_ Heater_D.W. O-fAW Compensation provisions of.the Labor Code, you must forth- Oven _ Dryer _ W.M. ADDRESS 7 r�s�a��/ r- with comply with such provisions or this permit shall be Top — FAU .—W.H.* deemed revoked. CITY Tel. No�ala-W-4 Hood _ Fan Ot er E'l Li LICENSED CONTRACTORS DECLARATION I_ W LICEN OR a Disp. J_ Room Air ona: y�� Class. �o I hereby affirm that I am licensed under provisions of Chapter 9 REG. NUMBER (commencing with Section 7000) of Division 3 of the Business DISTRICT N PRO BY Il and Professions Code,and my license is in full force and effect. Power Apparatus& Large Appliances 57 � / d Size &Type HP, KW, KVA, or KVAR' (/ U License Number 7-7 f� �Lic. Class Up to 1 Incl lj /�'� •� FINAL Contractor. °lD1-d It f 96< tate � Over L to lO,Incl. DATE VALI tOPd I— ❑ • ", Over 10�to 50 Incl. FINA W I am exempt under Sec: Over 50 to 100 Inc. BY B.&P.C. for this reason Over 100 Z Date: Services, Swbd., MCC& Panelboards 0 -200 Amp. Under 600 V Signature 201 - 1000 Amp. Under 600 V ;2 4 3'31 5A ❑ Over 1000 Amp. or Over 600 V Exemption for Reg. Maint. Elect. # o o,oro o 2 SINGLE FAMILY Temp. Power Pole&Appurtenances HOME OWNER-BUILDER DECLARATION 3 Q Sign with One Branch Circuit 00 0 I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits 0 o 3 6,0 0 Professions Code): ❑ I, as owner of the property, will do the work and the Misc. Conduits&Conductors 0 3t.3 1 t 86 structure is not intended or offered for sale (Section Other (See.Complete Fee Schedule)_ D 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) (Sec. 3097, Civ. C.). PLAN CHECKING FEE Lender's Name 6 PERMIT ISSUING FEE Lender's Address I certify that I have read this application and state that the TOTAL FEE b 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-me t'o a oper for inspection pu poses. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permits a Date