HomeMy Public PortalAbout6267 HART AVE_Electrical__ WORKERS'COMPENSATION DECLARATION CE 806G (2-80) QPPLOCATMN FOO Q EL EC U MICALb PERN T
''I hereby affirm that I have a certificate of consent to selfCOUNTY OF LOS ANGELES BUILDING AND SAFETY
insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec. 3800,Lab.C.)
66 ,�''..�� ,,p� 1�1 FOR APPLICANT TO FILL IN SOB
PolicyNo. ,,0'lJ�J�CompanyF�eVhC`►��`�-R3� l1� EACH NO. FEE ADDRESS IJ^
New'Residential Bldgs.&Pools
Certified copy is hereby furnished. 1 &2-Family,Sq. Ft. $ — $ LOC'ALITY �L 1—
❑ Multi-family Sq. Ft. NEAREST
Certified copy.is filed with the county building inspection CROSS ST In Lk4Z CL e-A)
department. Residential-Swimming Pools OWNER OR—
` .'
FIRM NAME) d�
Date -� i- ��Applicant Outlets: Rec.lLight Sw.� MAIL
First 20 3- ADDRESS
CERTIFICATE OF EXE PTION FROM WORKERS' Total No.��� Additional CITY Tel No
COMPENSATION INSURANCE,. PLAN CHECK d
APPLICANT O
(This section need not be completed ifthe the work involved U
First 20re
Fixtures us
by the permit is for one hundred dollars ($100) or less.) LigADDRESS cc
• Additional
Total No. O
I certify that in the performance of the work for which thisFixed Appliances'Not Over 1 HP CITY' Tel No.
U
permit is issued, I shall not employ any person in any manner PERMIT 1
so as to become subject'to the Workers' Compensation Laws. Range_ Heater D.W. APPLICAN
CUL,
rn
Oven _ Dryer_W.M._ ADDRESS AI. S lQ 1 z
Date �' d Applicant Top _ FAU _W.H. 3
Hood _ Fan _Other_ CITY' ��� 1_0 Tel No. _t Its's
NOTICE TO APPLICANT: f, after making this Certificate of Disp. Room Air Cond. LICENSE OR qt}
Exemption, you should become subject to the Workers' REG. NUMBER �p Class
Compensation provisions of the Labor Code, you must forth- Power Apparatus& Large Appliances DISTRICT NO. OC SSED BY
with comply with such provisions or this permit shall be Size&Type HP, KW,KVA,or KVAR '
deemed revoked. � G 6
Up to 1 Incl. -
FINAL
Over 1 to 10 Incl. DATE Q,.�
LICENSED CONTRACTORS DECLARATION Over 10 to 50 Incl. J VALIDATION
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 the Busi- Over 100 BY
ness and Professions.Code, and my license is in full force and
effect. Services
() 0-200 Amp. '
License Number 3 �•�;�' ) Lia Class Under. V*,� .
201-1000 Amp..Under 600 V
ContractorZE' Date ^!rte Ems— Over 1000 Amp.or'Over 600 V
ME OWNER-BUILDER DECLARATION Temp.Power Pole&Appurtenances ;
I her affirm that I am exempt from the Contractor's Sign with One Branch Circuit '
License Law for the following reason (Section 703Additional Sign Branch Circuits
.1.5, Busi- o /
ness and Professions Code):
Misc.Conduits&Conductors
F] wnI, as owner of property, we work anthe
f thtill do thk d structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)—
7044, Business,and Professions Code). .• 9, A
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency {,
for the performance of the work for which this permit is # 0 0 0 0 0 2
issued (Sec. 3097,Civ.C.). PERMIT FEE (Sub-Total).
Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee) 2 0 0.22,5.50
Lender's Address PERMIT ISSUING FEE 0 0 0 2 55 G'
I certify that I have read this application and state that the TOTAL FEE _ �� U 77. 1 —8 Q
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 inspec on purposes/.
" SEE'REVERSE FOR EXPLANATORY LANGUAGE
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S�gnature of Permittee Date!