HomeMy Public PortalAbout6277 HART AVE_Electrical__ WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12-91)
76A663 J
I hereby affirm that I have a certificate of.consent to self insure, APPUCAMN FOR EL EC MAL PER ISI T
or a certificate of worker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV.
copy thereof(Sec.3800 Lab. C.)
•
Policy No. Company - FOR APPLICANT TO FILL IN JOB /`�
❑ ADDRESS G 2 -� '. A R_T
Certified copy is hereby furnished. New Residential Bld &Pools NO. EACH FEE
❑ esidentgs. _ $ $ LOCALITY
.Certified co is filed with the count building inspection 1&2-Family,Sq.Ft.
copy y g P NEAREST
department. Multi-family Sq.Ft. CROSS ST.
Date Applicant Residential Swimming Pools ASSESSOR
MAP BOOK, PAGE PARCEL
Outlets:Rec. Light Sw.
CERTIFICATE OF EXEMPTION FROM WORKERS' � OWFIRM NERNAMORE /` u , 19,COMPENSATION INSURANCE _ , oU /_ -
First 20
(This section need not be completed if the work involved by the MAIL
IL s ,
permit is for one hundred dollars($100)or less.) Total No. Additional
I certify that in the performance of the work for which this permit CITY �—� Tel.No.
is issued, I shall not ernpl'oy any person in any manner s as to
Lighting Fixtures First 20 PLAN CHECK
become-subject to the.Workers' Compens ion Laws 9 9 APPUCAN7 •
Total No. Additional
2JSQ ADDRESS
Date Appf, nt F- RESIDENTIAL APPLIANCES NOT OVER 3 HP.
NOTICE/T ,AP,PLICANT: If, a r making this Certi tate of CITY Tel.No.
Exemption,.you should become subject to the Workers'Cogfpensation OTHER APPLIANCES NOT OVER 3 HP.
provisions of the Labor Code, you must forthwith comply with such PERMIT
provisions or this permit shall be deemed revoked. Power Apparatus&Large Appliances APPLICANT (Cw
LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS/ x eon n4.4e
I hereby affirm that I am licensed under provisions of Chapter 9 Over 3 to 10 Incl. ^
(commencing with Section 7000) of Division 3 of the Business and CITY A Tel.No.3 4
Professions Code, and my license is in full force and effect. Over 10 to 50 Incl. (J
Over 50 to 100 Incl. LICENS OR Class.
REG.NUMBER d
l/ Over 100 DISTRICT NO. P OC SED BY Q
License Number 14Y`� Lic.Class ^ j/ V
r ^ "'
Services,Swbd.,MCC&Panelboards /Q
Ir
Con actor ldv o�F�f C- Date�2-3-� d 0 O 0-399 Amp.Under 600 V FINAL 0
. _ DATE Q
I am exempt under Sec. ,�Q'�"�'Afip.Under 600 V �2-�9-�3
VALIDATION U
..Over 1000 Amp.or Over 600 V � FINAL/V/_
/V/_-
B.&P:C.for this reason t 3 BRANCH CIRCUIT FEES BY
Date: .L 3 3 15A,or 20A, 120V,Lighting or Recept. Z
1 To 10 Branch Circuits
Signature 4744 4Tce, _......... ........_. .. _
-11 To 40 Branch Circuits - -
41 Or More Branch Circuits
❑ Exemption for Reg.Maint.Elect. 15A,20A,208V To 277V Lighting Br.Circuits
SINGLE FAMILY Temp.Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION ='s
itch Cir
Br
with O
Sign wOne ancu
I hereby affirm that I am exempt from the Contractor's License LawSig -+-.r•'-• n �;:_
for the fallowing reason (Section 7031.5,'Business and Professions Additional Sign Branch Circuits L.,_I{
-
Code): -
❑ I, as owner of the property,will do the work and the structure Misc.Conduits&Conductors , 30
Tf_{ s L i • ,
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule)
and'Professions Code). hf =°
CONSTRUCTION LENDING AGENCYHA
I hereby affirm that there is a construction lending agency for the (" rf-u
performance of the work for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total)
Civ. C.) _ _
PLAN CHECKING FEE sem!Lender's NameCl
PERMIT ISSUING FEE --- -
Lender's Address -
I certify that I have read this application and under penalty of purjury state TOTAL FEE h o
that the above information is correct. I agree to comply with all County
ordinances and Sy]awsegulating lectrical wiring,and hereby authorize
se atives ont oe r upon the above-mentioned property
for i s ection puSEE REVERSE FOR EXPLANATORY LANGUAGE
/ZA _3
S N URE OF PEITIMITTEE DATE -