HomeMy Public PortalAbout6013 HART AVE_Electrical__ " WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12-91) pp ��aa ��pp 2pp C�a p� IC§�pp �p
76A663 APPL�IrllA�0 N FOR LSL��1Ls�lf A�rl96�L� �����T (J
I hereby affirm that I have a certificate of consent to self insure, `
or a certificate of Work'qr's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV.
copy the Eof•(Sec`3800La�b. C.)
Policy NO.�- Company'�/'� P FOR APPLICANT TO FILL IN JOB
ADDRESS
❑ Certified•copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE LOCALITY
❑ 1 &2-Family,Sq.Ft _ $ $
.
Certified copy is filed with the county building inspection NEAREST
department. Multi-family Sq.Ft. CROSS ST. /
Residential Swimming Pools ASSESSOR
Date Applicant MAP BOOK
PAGE PARCEL
OR
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec._Light Sw. FFIIRM NAME l 1
COMPENSATION INSURANCE
First 20 MAIL
(This section need riot be completed if the work involved by the Total No. Additional "ADDRESS Q
permit is for one hundred dollars($100)'6r less.)
I certify that'in the performance of the work for which this permit CITY Tel.No.
is issued, I shall not employ any person in any manner so as t0 PLAN CHECK
become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 APPLICANT 7
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.
ovisions of the Labor Code, ou must forthwith compI with such PERMIT
p y p y Power Apparatus&Large Appliances APPLICANT:
provisions or this permit shall be deemed revoked..
LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS
hereby affirm that l am licensed under provisions of Chapter 9 Over 3 to 10 Incl.
(commencing with Section 7000) of Division 3 of the Business and CITY
Over 10 to 50 Incl.
Professions Code,and my license is in full force and effect. LICENSE OR }
Over 50 t0 100 Ind. REG.NUMBER 1 � Class.C-20 CL
O
License Number
O Over 100 DISTRICT NO. PR SSED BY
�✓� "'+� Lic.Class V
Services,Swbd.,MCC&Panelboards
!_2_-k .� � 0-399 Amp.Under 600 V FINAL
Contrac a�b �' Date DATE j /(J
El 'I am exempt under Sec. 400-1000 Amp.Under 600 V s I Z5 C/ / W
VALIDATION
_ Over 1000 Amp.or Over 600 V FINAL d
B.&P.C,-for this reason _ BRANCH CIRCUIT FEES
BY
Date:' 0 5A,or 20A, 120V,Lighting or Re.cept.
1 To 10 Branch Circuits
Signature 11 To 40 Branch Circuits
❑ 41 Or More Branch Circuits
Exemption for Reg.Maint.Elect. 15A,20A,208V To 277V Lighting Br.Circuits
SINGLE FAMILY Temp.Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION
hereby affirm that, am exempt from the Contractor's License Law Sign with'One Branch Circuit
_0
330....
n .e
for.the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits * ..
Code):
❑ NS
Misc.Conduits&Conductors' L
u
I,as owner of the property,will do the work and the structure s
is not intended or offered for sale Section 7044, Business Other See Complete Fee Schedule
and Professions Code). —-•
PECK f o4
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.)
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 6=4v 2
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 Or PERMITTEE ATE