HomeMy Public PortalAbout6129 HART AVE_Electrical__ WORKERS'.GOMPENSATION DECLARATION ; 76A663 10/81 I�
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CE-806G_ I!':PUtbdilll ON FOR ELECTMICAL..PERNT
1 hereby-".affirm thla,•-I have a.certificate of consent to self insure,
or,.a certificate of Workers' Gonipensation Insurance, or, a b¢rtified COUNTY'`OF,LOS ANGELES BUILDING AND SAFETY
copy thereof(Sec..3800 Lab. �^
Policy No:•- Company"Y�l�i /I/,d uo6 t� 1Z7
Y; New Residential Bld S FOR'APPLICANT';?O FILL IN` ��
�,/3� . ._ ADDRESS
1.
' ❑ Certified copy is here6 furnished g . & Pools.
-
EACH NO,
❑ —
Certified copy is filed with the:�county building'inspection 1 & 2 Family,Sq.F
t
depar ment. Multi-family Sq.Ft.
$ �LOCALITY�,
NEAREST'
Residential.Swimming'Pools CROSS,ST. �i�`��'�•�'
Date... `` AP.Plicant X
..,._ •� •.' r,- ._ , - +�.:r WNER OR
FFIIRM NAME
CERTIFICATE OF.EXEMPTION FROM WORKERS,, Outlets:Rec—''Light <Sw x ' 4 MAIL �-
COMPENSATION"INSURANCE; k. ADDRESS. �? . Glomi�y
„z(This section need not be completed.if the work involved by the. First 20 `
per ris for one:hundred dollars ($,100)or.less.) .
Total No. Addihonal rr CITY. Tel No.
'rl,certrfy,that'in-the.performance of.the.work for which this,permit APPLCANTK
„ . Y ,so as to ;
is issued,.I ;hal',not•employ any,person do any, , Lighting Fixtures First 20'; ° Y 'ADDRESS
k
become'sub ect to-the Workers'Com en'ation•Laws
r, -
Additional Y.
Total No. CITY Tel:No.'
Date Applicant
Tof ....-
NOTICE TO APRLICANT .'If; after `makin this Certificate of r Fixed Appliances Not Over 1:HP APPMIT
, 9`•r
Exemption,you'should become subject to the Workers'Compensation Range-7—
,-,mu
ange'_ Heater_
. ,r• NT /
C''aN
provisions of the.-Labor Code,you must forthwith comply with such Oven Dryer " W.M. ., ADDRESS
prowsio
ns.or this permit
shall deemed revoked Top FAU.`_.W.H
LICENSED CONTRACTORS DECLARATION Hood Fan- ,_ Other-.•
CITY � � Tel.No. 7�
I hereby.affirm that I am licensed under provisions of Chapter 9 Dlsp Room Air Cond.:. - LICENSE OR
., , , s . .. _ REG.NUMBER "` '/'` / `
(commencing with.Section 7000) of Dlvlsion.3 of the Business and
Class.•-
Profession's Code,and myiicense is in.full force and effect. DISTRICT NO
Power,Apparatus& Large Appliances,
. PROCES B
CL,
/J
Size_&Type HP,KW KVA or KVAR d�
License Number7 ic�Class .' Up to 1`Incl .
� L . FINAL
Q �/
Over 1 to.10 Incl
a/moi / (/ 'Dafe , �.,: :,
Contractor' / Over 10 to 50 Incl U
DATE'
FINAL
I am azempt-under Sec': ;: M, __.Over 50 to,100 Inc. BY. W
B.&P.0 for this reason
Over 100 : .
Date: ,_..
Services Swbd.,MCC& Panelbcards ,.
v,,. . 0 :200,Amp.Under 600 V
SidnaturA ` '201,.1.000 Amp.Under 600 V
❑V, c, , rnp. o
Over,1000 A r Over 600 V,
Exemption for Reg.Maint Elect. j
SINGLE FAMILY : Temp Power Pole& Appurtenances
HOME OWNER-BUILDER DECLARATION' Sign with One Branch Circuit
I hereby.:affirm'that.I amnexempt from the Contractor's License'Law. -
for the following reason(Section 703,1.5, Business and Professions,. Additional'Sign Branch Circuits, ', ,._ : AC�.Ti,.0,
Code) It}}�
au°. 203 o �
❑ Misc Con "its& 3 Conductors
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)._ 'I ITEMS
_i
and Professions Code).
v. TOTAL • 3.5 -,96 .
CONSTRUCTION LENDING AGENCY �, (t35 9
I hereby affirm tfiat there is construction lending agency for the,
4
GASH
performance of the'tvork for which this permit is,issued(Sec.3097, PERMIT FEE .
(Sub-Total) y�Q. CHANGE.: ,00
.y
Civ.C.
,. .
PLAN CHECKING FEE
Lender's Name . _ G��II�i +
PERMIT ISSUING FEE Qd 0001
Lender's'Address ���� PM `*.31 ,
I certify that I have read this application and state that the above TOTAL FEE 3� ��y
1
information is correct. I agree fo•comply with all County ordinances
and at Maws regulating Electrical wiring, and hereby authorize
re P" sent tives„of this,County to enter,upon.the above-mentioned
trgn
or inspection purposes. SEE,REVERSE 1 OR,EXPLANATORY LANGUAGE '
ofPerDa e