HomeMy Public PortalAbout6272 HART AVE_Electrical__ WORKERS' COMPENSATION DECLARATION CE-806 10/81 ArPp CAMOp n FOR ELEC MCAL PERNT
I hereby affirm that I'have,.f'a+certificate of consent to self insure, CE-806G I� ��J LS L4 u
or a certificate of Workers'`Compen,;ation Ir78urance, Cr a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof(Secy 3800,Lib.C.)'•J)
Policy No. Company - FOR APPLICANT TO FILL IN JOB
❑ Certifiedbopy is,hereby furnisfed EACH NO. FEE ADDRESS (927
y New Residential Bldgs.& Pools.
LOCALITY
Certified
Certified copy .is.filed with the-county building inspection 1 & 2-Family,Sq.Ft. $ — $
department. - Multi-family Sq.Ft. _ NEAREST
Residential Swimming Pools CROSS OWNER OR
Date Applicant O
FIRM NAME //v0 - V O L- -
CERTIFICATE OF EXEMPTION FROM WORKERS' w. MAIL
First 2
COMPENSATION INSURANCE Outlets:Rec— Light'— t 20 ADDRESS
(This section need not be completed if the work involved by the
permit is for one hundred dollars($100) or less.) Total No. Additional. CITY
. A-,-145Te1.No.Z,&--57'8
+ i / • '� PLAN CHECK -
I certify that in the performance of the work for which this permit APPLICANT
s'issued, I shall not employ any person in any,manner so as
become subject to the Workers'Comp nsatioo,4aws. Lighting Fixtures First 20 ADDRESS s
N�^� Additional
CITY Tel.No.
Date Applicant ixed ppliances Not Over 1 HP PERMIT
NOTICE./TO APPLICANT: If, after making this Certificate of b
Exemption,you should becomeaubject to the Workers Compensation Range_ Heater_'D.W. _ APPLICANT
provisions of the Labor Code, you must forthwith comply with such Oven _ Dryer _ W.M._ ADDRESS j
provisions or this permit-shall be deemed revoked: Top — FAU _ W.H,
CITY Tel .No.
LICENSED.CONTRACTORS DECLARATION Hood — Fan _ Other_
I hereby affirm that I am,licensed under' provisions of Chapter 9 LICENSE OR
Disp. — Room Air Cond. REG.NUMBER, AJ Class.
(commencing with Section 7000) of Division 3 of the Business and
Professions Code,and my license is in full force and effect. _ DISTRICT N0. PR CESS_ BY
Power Apparatus& Large Appliances
Size& Type HP,KW,KVA,or KVAR O
License Number Lic. Class Up to 1 Incl FINAL U
Over 1 to 10 Incl DATE
Contractor Date � VALIDATION 0
I
❑ Over 10 to 50 ncl. FINAL U
I am exempt under Sec. Over 50 to 100 Inc. BY W
BAP.O. for this reason Over 100 la
r N
Services,Swbd.,MCC& Panelboards Z
Dater 0- 200 Amp:Under 600 V
Signature 201 - 1000 Amp.Under 600 V 1
Over 1000 Amp.or Over 600 V
❑ Exemption for Reg.Maint.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 Law ' r
for the following reason (Section 7031.5,.Business and Professions Additional Sign Branch Circuits
:
Code 31
) a,:��f 31.00
❑ I,as owner of the property,will do the work and the structure Misc.Conduits & Conductorso. ITEMS
Other( p )
is not intended or offered for sale (Section 7044, Business _- � --.
and Professions Code). p TOTAL 3"11® 00
CONSTRUCTION LENDING AGENCY CHECK `1.0I
I hereby affirm that there is a construction lending agency for the ."'HAt'GE .011
i1i
performance of the work for which this permit is issued(Sec.3097, PERMIT FEE (Sub-Total) t S
Civ.C.).
PLAN CHECKING FEE
Lender's Name 1301713'1..31301 5/11/90
PERMIT ISSUING FEE Q
Lender's Address C1623 1 AM 84-53.
I certify that I have read this application and state that the above TOTAL FEE U
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 upowe-mentioned
propert or inspection rp es.
SEE REVERSE FOR-EXPLANATORY LANGUAGE
` Signature of Permittee Date i
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