HomeMy Public PortalAbout6141 HART AVE_Electrical__ ORKIfZS,'COMPENSATION DECLARATION' 76A663 10/81 0 0 0 0 0 0
eJet,"Maffirm that I hove a certificate of consent to self CE-806G APPUC�AIMN FOR ELECYQDCCad PERMT
+•- inSuFe, or a certificate-of Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified copy thereof (Sec. 3800, Lab. C.)
y •
Policy No. Company FOR APPLICANT TO FILL IN' _ JOB
Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADDRESS j P-
icy$
1 & 2-Fomil $ — LOCALITY T�
❑.
Certified copy is filed with the county building inspec- Y- S.q• Ft. —
tion department. Multi-family Sq. Ft. NEAREST
T.
CROSS
Residential Swimming Pools OWNER OR
Date Applicant FIRM NAME e7 \-,"e_v
CERTIFICATE OF EXEMPTION FROM WORKERS' MAIL
COMPENSATION INSURANCE Outlets: RecLight Sw.�, iy ADDRESS
��n First 20
(This section need not be completed if the work involved by Total No's Additional CITY TeL No2S6,5111
the permit is for one hundred dollars ($100)or less.) 3 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'_Compensation'Laws. Lighting Fixtures First 20 ADDRESS �.
Total No. Additional
- CITY � Tel:No.
Date Applicant fixed Appliances Not Over 1 HIP PERMIT
NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT
Exemption, "you should become 'subject to the Workers' Range_ Heater_D.W.
Compensation'provisions of the Labor Code,-you must forth- Oven Dryer W.M._ ADDRESS
with comply with such provisions or this permit shall be Top FAU —W.H. —
deemed revoked. _ Fan CITY Tel. No.
Hood
LICENSED CONTRACTORS DECLARATION Other_
"LICENSE OR
I hereby affirm that I am licensed,under provisions of Chapter Disp. — Room Air Cond. REG. NUMBER ' Class.
(commencing with Section 7000) of Division 3 of the Business DISTRICT NO. PRO SED BY
y Power Apparatus& Large Appliances
and Professions Code, and m license is in full force and effect. i
• Size &Type HP, KW, KVA, or KVAR: O
License Number. Lic. Class Up to 1 Incl FINAL U
Over 1 to 1.0 Incl. DATE �� —� VALID TION 0
Contractor Date Over 10.to 50 Incl.
FINAL �
EJI am exempt under Sec. Over 50 to 100 Inc. BY
B.&P.C. for this reason Over 100 H
Date: Services, Swbd., MCC & Panelboards (1U D t �'4, 8 A.
0 -200 Amp. Under 600 V lJ
'# o,o m'o 0 2
Signature 201 -1000 Amp. Under 600 V
❑
Exemption for Reg. Maint. Elect. Over 1000 Amp. or-Over 600 V '•'I o o b a 7 5
SINGLE FAMILY Temp; Power Pole &Appurtenances o'o o 6 8.7 5 6:
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am"exempt from the Contractor's LicenseAdditional Sign Branch Circuits G �'`3 0 8 5
Law for the following reason (Section 7031.5, Business and
Professions Code):
C-J I, as owner of Misc.the property, will do the.work and the Conduits& Conductors
,
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_
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 'n
PERMIT ISSUING FEE U 6
Lender's Address
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
t e above-mentioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
SignatulIe of Permittee t Date