HomeMy Public PortalAbout6132 IVAR AVE_Electrical__ WORKERS'COMPENSATION DECLARATION 76A663, 10/81 0 0 0 0 0
I hereby affirm that I have a certificate of consent to self CE-806G appdOC�Q��OO [BOO Q Cd[ C� Q�C�Qd p�� 0�
insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES �t - BUILDING AND SAFETY
or a certified copy thereof (Sec. 3800, Lob. C.)
Policy No. Company FOR APPLICANT 70 FILL IN JOB
ADDRESS i,7
Certified copy.is hereby furnished. New Residential Bldgs. & Pools EACH NO'. FEE
EJ Certified
LOCALITY
Certified copy is filed with the county building inspec- 1 & 2-Family, Sq. Ft. $ — $
tion department. Multi-family Sq. Ft. NEAREST a,
Residential Swimming Pools CROSS ST.
Date Applicant OWNER OR
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' MAIL
COMPENSATION INSURANCE Outlets: Rec Light Sw. ADDRESS-
This section need not.be completed if the work involved b First 20
( p Total No. CITY Tel. No.
the permit is for one hundred dollars ($1D0)or less.) Additional
performance-of the.work for which this PLAN CHECK
I certify '
that in the P er ' V APPLICANT
permit is issued, I shall not employ any person in any'manner
so as to become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 " ADDRESS
r
Total No. Additional
(� <
Ddte �_J Applicant 'J CITY Tei. No.
Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT
Exemption, you should become subject to the Workers' Range_ Heater.D.W. —
Compensation provisions of the labor Code;,you must'forth- Oven _ Dryer W.M!— ADDRESS
with comply with such provisions or this permit shall be Top _ FAU —W.,H. —
deemed revoked. Hood Fan _Other_ CITY C� Tel. No. Sy
.LICENSED CONTRACTORS DECLARATION LICENSE OR Class.
Disp. _ Room Air Cond.
I hereby affirm that l am licensed under provisions of.Chapter 9 REG. NUMBER C-fb
(commencing with Section 7000) of Division 3 of the Business DISTRICT NO. PROCESSE BY
and Professions Code,and•m license is in.ful_I ff
force and eect. Power Apparatus& Large Appliances }
Y Size& Type HP, KW, KVA, or KVAR' �
License Number-jj, !21 Lic. Class'C-1OFINAL V
Up to 1 In r*�»w a
/J�X f/!U r � DC7 9bte 09
Over 1 to 10 Incl. DATE , , a y� VALIDATION
Contractor' Over 10 to 50 Incl. I-.
FINAL
I am exempt under Sec. Over 50 to 100 Inc. BY t�aL
B.&P.C. for this reason' Over 100 h
Serwa
vices, Sbd., MCC& Panelboards ((�
Date: 0 -200 Amp. Under 600.V D `'
Signature 201 - 1000 Amp'. Under 600 V
F-1 Over
Over 1000 Amp. or Over 600 V
Exemption for Reg. Maint. Elect.
SINGLE FAMILY Temp: Power Pole-&Appurtenances 2.5 0'5.9
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License # o 018 0 0 12
Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits
Professions Code): - Z`o 0 2 5;5 Q
I, as owner of the property, will do the work and the Misc. Conduits & Conductors olo o z
structure is not intended or offered for sale (Section Other (See Complete Fee.Schedule)_ D 2' 15�,�
7044„Business a4Professions Code). "
9;09-,8,�, ,
CONSTRUCTION LENDING AGENCY
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 �o
above information is correct. I agree to comply with all County
ordinances and State laws regulating'Electrical wiring, and
hereby author' a representatives of this County to enter upon -'
the above- en Toned ro er inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
f"Si of'Permitlee Date