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Home My Public Portal About6221 HART AVE_Electrical__ WORKERS' COMPENSATION DECLARATION 20-0019oPw,3i87 n n��-� ��pn �O� ��^�� I hereby Efffirm that 1 have a certificate of consent to self CE-806G AP N �( insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS or a certified copy thereof (Sec�-3800, Lab..C.) Policy No. Company FOR APPLICANT TO FILL IN JOB ' LFIE Certified copy'is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE. ADDRESS Q Zt A -;y,,�� P ,� Certified copy is filed with the county building inspec- 1 8 2-Family, Sq. Ft. LOCALITY$ _ $ I �YyIP( -_ (24 ` y� tion department. Multi-family Sq. Ft. NEAREST Residential Swimming Pools -7 CROSS oolsCROSS ST. Date Applicant OWNER OR FIRM NAME �G►�� r)�t:[[NN CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Reca-Light�Sw.� MAIL COMPENSATION INSURANCE First 20 ADDRESS 2Z :� (This section need not be completed if-the work involved byTotal No, Additional CITY 'Gy Tel. No.�� , --jl the permit is for one hundred dollars ($100)or less.) PLAN CHECK I certify that in the performance of the work for which this APPLICANT permit is issued, l shall not employ any person in any manner so as to become subject to the Workers'.Compensation Laws. Lighting Fixtures First 20 A ADDRESS Additional Total No. CITY Tel. No. Date Applicant - Fixed Appliances Not Over } HP PERMIT NOTICE TO APPLICANT: If' after making this Certificate of APPLICATION Exemption, you should become subject to the Workers' Range— Heater—D.W. Compensation provisions of the Labor Code, you must forth- Oven 1 Dryer -L W.M.L ADDRESS with comply-with such provisions or this permit. shall be Top FAU L W.H. — deemed revoked. CITY TelNo. Hood -�- Fan —Other_• LICENSED CONTRACTORS DECLARATION LICENSE OR I hereby affirm that I am licensed under provisions of Chapter 9 Disp. _ Room Air Condi _ REG. NUMBER Class. (commencing with Section 7000)of.Division 3 of the Business Power Apparatus& Large Appliances DISTRICT N�o� PR SSED Y and-Professions Code,and my license is in full force and effect. G' ll Size &Type HP,KW, KVA, or KVAR �� O License Number Lica Class Up"to 1 Incl. FINAL C1 Over 1 to 10 Incl.: DATE ?) n VALIDATION 0 Contractor Date aOver 10 to 50 Inch FINAL u ~ I am exempt under Sec. Over 50 10 100 Inc. BY W B.&P.C. for this reason Over 100 D_ VV N • Services, Swbd., MCC &.Panelboardsa � D %• Z Date: 0.-200 Amp. Under 600 V J — . Signature 201 1 000Amp. Under 600 V F-1 Over 1000 Amp. or Over 600 V Exemption for Reg. Miaint. Elect. SINGLE FAMILY Temp. Power Pole &Appurtenances HOME OWNER-BUILDER DECLARATION Sign with•One Branch Circuit I hereby affirm that I am exempt from the Contractor's License g (:it:f,g Law for the following reason (Section•7031,5, Business and Additional Sign Branch Circu-its t rofessions Code): 3307 E+'+ cel _ Jle5 Misc. Conduits&-Conductors i r 1, as owner of the property,,will do,the work and the i I ';- structure is not intended or.offered for sale(Section 7044, Other (See Complete.Fee Schedule)— Business and Professions Code). yam, o . a CONSTRUCTION LENDING AGENCY CHECK r .. :,ti I hereby affirm that there is a construction lending agency for �- . iHftvE the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) ofl[l (Sec. 3097, Civ. C.). PLAN CHECKING FEE Lender's Name E jIZt�Q--I �jf �+: :'�'* PERMIT ISSUING FEE Lender's Address 7 77i fitl'EJ[1:Cly 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 pr4nonces and State laws regulating Electrical wiping, and he b out rize representatives of this County to enter upon I a v m ntioned property for inspection purposes.. SEE REVERSE FOR EXPLANATORY LANGUAGE /� I Lam► `� : ignature of Permittee Date ©s