HomeMy Public PortalAbout6053 HART AVE_Electrical__ WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12-91) APP L� �I CAM n FOR ELECT ICA L� PERNT - �f
I hereby affirm that I have a certificate of consent to self insure, 76A663
or a certificate of Worker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV.
copy thereof.(Sec. 3800 Lab, C.)
Policy No. • Company FOR APPLICANT"TO FILL IN JOB ,
ADDRESS
Certified co is hereby furnished. NO. EACH FEE
copy Y New Residential Bldgs.&Pools LOCALITY
$ $Ft
Sq. . —
Certified copy is filed with the county building inspection 1 &2-Family, _ NEAREST
department. Multi-family Sq. Ft. CROSS ST.
Date' Applicant Residential Swimming Pools ASS SSOR
PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec._Light Sw. OWNEROR
IRM NAME
COMPENSATION INSURANCE -�
First 20 MAIL '
(This section:need not be completed if the work,involved by the Total No. Additional ADDRESS S 3 �J,
permit is for one hundred dollars($100)or less.)
'-' Tel.No. ry
I certify that in the performance of the work for which this permit CITYpr •- OZz
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 complywith such PERMIT
P y t Power Apparatus&Large Appliances APPLICANT
provisions or this permit shall be deemed revoked.
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 CITYT GI- Tel.No.
Professions Code,and my license is in full force and effect. Over 10 to 50 Incl.
LICENSE OR Class. >
Over 50 to 100 Incl. REG.NUMBER � a
Over 100 DISTRICT NO. eR ES EO BY Q
License Number Lic.Class G C V
- Service ,Swbd CC&Panelb rc�d� q �Q CC
Contractor Date '- 0-399 Amp.4nderr 6/00 VV�Y � FINAL DATE 0
El400-1000 Amp.Under 600 V
I am exempt under Sec. VALIDATION V
Over 1000 Amp.or Over 600 V FINAL LU
B.&P.C.for this reason BRANCH CIRCUIT FEES BY
Cn
Date: 15A,or 20A, 120V,Lighting or Recept. Z_
1 To 10 Branch Circuits
Signature 11 To 40 Branch Circuits -
❑ _ 41 Or More Branch Circuits f'=•`�
Exemption for Reg.Maint.Elect. 15A,20A,208V To 277V Lighting Br.Circuits
SINGLE FAMILY Temp.Power Pole&Appurtenances -
HOME OWNER-BUILDER DECLARATION 1 ITEM'S I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit ' - Gi =
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits ._a
Code): ._..
Misc.Conduits&Conductors 6`
I,as owner of the property,will do the work and the structure
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule)
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 (Sec. 3097, PERMIT FEE (Sub-Total) 71Q=.171 M 85=
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 inspeFtion purpose SEE REVERSE FOR EXPLANATORY LANGUAGE
IGNATURE OF PER TTEE DATE