HomeMy Public PortalAbout6161 HART AVE_Electrical__ WORKERS'COMPENSATION DECLARATION CE-E0676A663
CE-8061081 APPUC ATMN FOR ELECT TPUC AL PERN'T
I hereby affirm that I have a certificate of consent to self G
insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified copy thereof (Sec. 3800, Lab. C.)
Policy No. Company FOR APPLICANT TO FILL IN JOB
Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADDRESS '
❑ 1 & 2-Family, S Ft. $ — $ LOCALITY
Certified copy is filed with the county building inspec- Y. q
NE
ARET
tion department. - Multi-family Sq. Ft. _ CROSS SST. � -
Residential Swimming Pools OWNER T. -
Da a plicont
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' 1Qf MAIL
Outlets: Rec Light '_'t_Sw.
COMPENSATION INSURANCE C ADDRESS
(This section need not be completed if the work involved by (A First 20
the permit is for one hundred dollars ($100)or less.)
Total No. (A Additional CIT Tel. No.
CK
I certifythat in the performance of the work for which this PLAN C ET
p - APPLICANT ArLtZ
permit is issued, I shall not employ any person in any manner
so'as To become subject to the Wor Compensat'on Laws. Lighting Fixtures First 20 ADDRESS
Total No._N Additional CIT)-j— Tel. No.
Dat pplicant Fixed Appliances Not Over 1 HP. PERMIT
NOTICE TO APPLICANT: If, after making this �rtifi -! APPLICANTExemption, you should become subject to thrsRange_ Heater_D.W. —
Compensation provisions of the Labor Code, youth- Oven — Dryer — W.M.— ADDRESS
with .comply w.ith such provisions or this permit shall be' Top FAU —W.H. —
deemed revoked, - Hood _ Fan _Other CITY Tel. No.
LICENSED CONTRACTORS DECLARATION LICENSE OR
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. - REG. NUMBER Class.
(commencing with Section 7000) of Division 3 of the Business DISTRICT NO. PROCESSED
and Professions Code,and m license is in full force and effect. Power Apparatus& Large Appliances A
y Size&Type HP, KW, KVA, or KVAR' 6-t Cyt ' o
License Number Lic. Class Up to 1 Incl. FINAL U
Over 1 to 10 Incl. DATE VALID I fd O
Contractor Date Over 10 to 50 Incl.
FINAL I.—
ElI am exempt under Sec. Over 50 to 100 Inc. BY LU
B:&P.C. for this reason Over 100. H
Services, Swbd. lb rj - D
Date: 00 Amp. Under 600 V
Signature 201 - 1000 Amp. n tL
Over 1000 Amp. or Over 600 V
Exemption for Reg. Maint Elect. : 03 32 A
SINGLE FAMILY Temp. Power Pole& Appurtenances
HOME OWNER-BUILDER DECLARATION ,1# 0 0 0.6 o 2
Sign with One Branch Circuit
1 hereby affirm that I am exempt from the Contractor's License o 0 Additional Sign Branch Circuits x
Law for the following reason (Section 7031.5, Business and g :0.0 o %8,7 5 2
Professions Code):
Misc. Conduits&Conductors 0 8.02 y 8 8
I, as owner of the property, will.do the work and the
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ D
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY f
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
PERMIT ISSUING FEE
_Lender's Address '
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
ordino es and State laws regulating Electrical wiring, and
her y uthorize represe tatives of this County to enter upon
th abo e-mention d pr rty f spection purposes.
�y SEE REVERSE FOR EXPLANATORY LANGUAGE
Si nature of Permittee Date' r, `='