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Home My Public Portal About6117 HART AVE_Electrical__ 63 WORKERS'COMPENSATION DECLARATION 76 66G (2-80) L�1P L ICA U �OO Uhl FOR EL EC U IIUCAL� I�LSh\CN Il I,hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELS BUILDING AND SAFETY insure, or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec. 3800,Lab. C.) e I Company FOR APPLICANT TO FILL IN JOB Policy No. ADDRESS �,` New Residential Bldgs.B�Pools EACH NO. FEE Certified copy is hereby furnished. 1 &2-Family,Sq. Ft. �� $ — $ d LOCALITY � `e, c-N-C-\ Multi-family Sq. Ft. NEAREST Certified copy is filed with the county building inspection CROSS ST Residential Swimming Pools i1n department. NER OR p RM NA Ef \ '1 Date Applicant Outlets: Rec._Li ht_'Sw. ? MAIL p A g First 20 ADDRESS X \:pL� CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. Additional CITYS p,,�J o. �.-•� gad } COMPENSATION•INSU RANCE PLAN CHECK (This section •need not be completed if the work involved APPLICANT p by the,permit is for one hundred dollars ($100) or less.) Lighting Fixtures First 20. ADDRESS C1 Additional Total No. I_ certify that in the performance of the work for which this Fixed Appliances Not Over 1 HP CITY Tel N'o. F- permit is issued, I shall not employ any person in any manner PERMIT - U so as to become subject to the Workers' Compensation Laws. Range_Heater—D.W. APPLICANT_ lei l O W Oven _ Dryer_'W.M. ADDRESS W 9r / �� 1 Top — FAU —W.H.. CITY ie�l No. �( Dat � � Applicant ,- -- r Hood _ Fan _Other_ 7j NOTICE TO APPLICANT: If,after making this Certificate ofDisp. _ Room Air Cond.— LICENSE OR ! 1 Exemption, you should become subject N751(;Z to the Workers' REG. UMBER 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 deemed revoked; Size&Type HP,KW, KVA,or KVAR Up to 1 Incl. FI Over 1 to 10 Incl. DATEL LICENSED CONTRACTORS DECLARATIONOver 10 to 50 Incl. VALI DATION I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. FINAL 9 (commencing with Section 7000) of Division 3 of tBusi- Over 100 BY he ness and Professions.,Code, and my license is in full force and /I effect. Services 0-200 Am Under 600 V License Number Lic.Class��`��-/ p. ,� 201-1000 Amp. Under 600 V , Font ra CtOf]c.�` 1-�� .t-Cpate � Over 1000 Amp.or Over 600 V `i ,J HOME OWNER-'BUILDER DECLARATION Temp. Power Pole&Appurtenances I hereby affirm that- 1 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 ness and Professions Code): Misc.C0 2 7 7,3 A onduits&Conductors � , ' a - ❑ •1, as owner of the property,,will do the work and the Other(See Complete Fee Schedule)—' structure is not intended or offered for sale (Section # o o o o o 2 7044, Business and Professions Code). n CONSTRUCTION LENDING AGENCY 2 0 o 9 /,9 Q I hereby affirm that there is a construction lending agency ' for the performance of the work for which this permit.,is 9� 0 0 0 9 7,9 0 6 issued(Sec. 3097,Civ.C.). PERMIT FEE (Sub-Total) 7 Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee) _ 1 0,24-78,0. Lender's Address PERMIT ISSUING FEE I certify that I have read this application and state that the TOTAL FEE 7 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 Signat, a of Permittee Dat WORKERS'COMPENSATIONDECLARATION CE-806 APPUCAMN FOR ELEC CAL PERNT Ivhereby 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 a certified copy thereof(Sec. 3800,Lab.C.) FOR APPLICANT TO FILL IN SOB Policy No. Company EACH NO. FEE ADDRESS / New Residential Bldgs.&Pools Certified copy is hereby furnished. 1 &2-Family,Sq. Ft. $ — $ LOCALITY ❑ Multi-family Sq. Ft. NEAREST Certified copy is filed with the county building inspection CROSS ST department. Residential Swimming Pools OWNER OR FIRM NAME Date Applicant Outlets: Rec._LightT Sw. MAIL First 20 ADDRESS CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. Additional CITY Ct�t r el'No. COMPENSATION INSURANCE } l PLAN CHECK a APPLICANT 0 (This section need not be completed if the work:involvedU' by the permit is for one hundred dollars ($100) or less.) _ Lighting Fixtures First 20 Additional ADDRESS Ir Total No. 0 I. certify that in the performance of the work for which this CITY) Tel No. Fixed Appliances Not Over 1 HP permit is issued, I shall not employ any person in any manner PERMIT W so as to become subject to the Workers' Compensation Laws. Range_ Heater_D.W. APPLICANT i. a /. � Oven _ Dryer_W.M. ADDRESS toz Date Applicant Top _ FAU _W.H.. Hood Fan _Other_ CITY Te .No. NOTICE TO APPLICANT: 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_ PRO ES D BY with comply with such provisions or this permit shall be deemed revoked. Size&Type HP, KW,.KVA,or KVAR Js Up to 1 Incl. FINAL ` Over 1 to 10 Incl. DATE LICENSED CONTRACTORS DECLARATION Z �� VALIDATXON Over.10 to 50 Incl. - I hereby affirm that I am licensed under provisions of Chapter Over 50 to.100 Inc. FINAL f 9 (commencing with Section 7000)'of Division.3 of the Busi- Over 100 BY ness and Professions.Code, and my license is in full force and effect. Services 0-200 Amp. Under 600 V License Number Lic.Class 201-1000 Amp. Under 600 V Contractor Date Over.1000 Amp.or Over 600 V HOME OWNER-BUILDER DECLARATION emp Power Pole&A�purte I hereby affirm that I am exempt from the Contractor's Sign wit One Branch Circuit I _ License Law for the following reason (Section 7031.5, Busi- Additional Sign Branch'Circuits ness and Professions Code): Misc.Conduits&Conductors Z 1, as owner of the property, will do the work and the Other.(See Complete Fee Schedule)— structure is not intended or offered for sale (Section J2 2 2 3 8 A 7044, Business and Professions Code).. CONSTRUCTION LENDING AGENCY # 0 0 0 0 0.2 I hereby affirm that there is a construction lending agency for the performance of the work for whichA this permit is PERMIT FEE (Sub-Total) 962 0 0 7,0 0 issued(Sec. 3097,.Civ.C.) 'r`� ` �� Lender's Name f ! 'c/J/ i� PLAN CHECKING FEE (One-Fourth Permit Fee) 0 0 0 1 -7.0 0� Lender's Addressr%YCiS-CAW pe4, llG/!Pv /r� e.,«�'� PERMIT,(SSUING FEE 09,23-80 I certify that I have read this application and state that the TOTAL FEE 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 he above-menti :d�forection purposes. SEE'REVERSE FOR EXPLANATORY LANGUAGE ignature of Permittee Date