HomeMy Public PortalAbout4928 GLICKMAN AVE_Electrical__ WORT COMPENSATION DECLARATION 9 DPW 9/89 A PPIL I� riON FOR ELECTRICAL PERMIT
76A66
I hereby affirm if rve a certificate of consent to self insure, 76A66 /1
3
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.) C A
-aU�o4� J r�r� •FC.I/IIf� FOR APPLICANT TO FILL IN JOB f f�'1j Y • yam(-��
Policy No. Company J hj[
ADDRESS
Certified copy is hereby furnished. New Residential Bldgs.&Poo EACH NO. FEE LOCALITY
Certified co is filed with the count building inspection 1 &2-Family,Sq.Ft. $ r d — $ 0
PY Y 9 P _ NEAREST
department. Multi-family Sq.Ft. CROSS ST.
Date Applicant Nu/•F • IAI G' Residential Swimming Pools ASSESSOR
PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec._Light Sw. OWNER
IRM NAME
COMPENSATION INSURANCE First
First 20 MAIL
(This section need not be completed if th rk involved by the Total No. Additional ADDRESS IIA3
permit is for one hundred dollars(31 or less.)
I certify that in the performanc f the work for which this permit CITY j� C5a6Yi' Tel.Nogg8
is issued, I shall not em any person in any manner so as to PLAN CHECK
become subject to orkers'Compensation Laws. Lighting Fixtures First 20 APPLICANT
Total No. Additional ADDRESS
Date Applicant 15 OR 20A,120V BRANCH CIRCUITS
N TICE TO APPLICANT: If, after making this Certificate of CITY Tel.No.
Exemption,you should become subject to the Workers'Compensation 1 TO 10 INCLUSIVE EACH
IT
provisions of the Labor Code, you must forthwith comply with such 11 TO 40 INCLUSIVE EACH APPLICANT /�/• (�, �N C-
provisions or this permit shall be deemed revoked. 41 OR MORE BRANCH CIRCUITS EACH ADDRESS
LICENSED CONTRACTORS DECLARATION 15 OR 20A,208V TO 277V LIGHTING EACH �� O
I hereby affirm that I am licensed under provisions of Chapter 9 (�
(commencing with Section 7000) of Division 3 of the Business and CITY S �L �7� Te1.No B/��Ldl-jam U
Professions Code,and my license is in full force and effect. RESIDENTIAL APPLIANCES UP TO 3HP LICENSEOR CSO
Power Apparatus&Large Appliances REG.NUMBER Q 7 class.
X70 7 C Size&Type HP,KW,KVA,or KVAR DISTRICT NO. PROCESSED BY
License Number Lic.Class
Up to 3 Incl. 12 0
Pelf—fit �� IJ
Contractor Date 7 Over 3 to 10 Incl. PANTE U)
❑ Over 10 to 50 Incl. m r , Z
I am exempt under Sec. Over 50 to 100 Incl. VALIDATION
AL
B.&P.C.for this reason
Over 100 BYAL
Services,Swbd.,MCC&Panelboards
Date: 0-200 Amp.Under 600 V
Signature 201 -1000 Amp.Under 600 V
❑ Over 1000 Amp.or Over 600 V
Exemption for Reg.Maint.Elect.
SINGLE FAMIL Temp.Power Pole&Appurtenances "
HOME OWNER-BUILDER ECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt fro the Contractor's License Law
for the following reason (Section 7 1.5, Business and Professions Additional Sign Branch Circuits
Code):
❑ I, as owner of the prop ty,will do the work and the structure Misc.Conduits&Conductors :.
is not intended or off red for sale (Section 7044, Business Other(See Complete Fee Schedule) ® _and Professions Cod ). — —
CONSTRU TION LENDING AGENCY -
I hereby affirm that there is a construction lending agency for the
performance of the work or which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total)
Civ.C.)
PLAN CHECKING FEE -.- --
Lender's Name
PERMIT ISSUING FEE p? „...:
Lender's Addre j rJ
I certify that have read this application and state that the above TOTAL FEE pc /
information s correct. I agree to comply with all County ordinances
and Stat laws regulating Electrical wiring, and hereby authorize
represe atives of this County to enter upon t bove-mentioned
proper fo spec ion pur ses SEE REVERSE FOR EXPLANATORY LANGUAGE
AT RE.QEIAPPUCANT OR AGENT DATE