HomeMy Public PortalAbout4938 GLICKMAN AVE_Electrical__ WORK[ )MPENSATION DECLARATION 20-0019 DPW 9/89
I hereby affirm tha e a certificate of consent to self insure, 76A663 APPLIC ION FOR ELECTRICAL PERMIT
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.) �/g� �9
Policy No. - Company `�(�/ 7 UW16 FOR APPLICANT TO FILL IN JOB
ADDRESS
E Certified copy' hereby furnished. New Residential Bldgs.&Pool EACH NO. FEE
LOCALITY
Certified copy is filed with the county building inspection 1 &2-Family,Sq.Ft. _depart NEAREST
ent. Multi-family Sq.Ft. CROSS ST.
Date Z Applicanty C• Residential Swimming Pools ASSESSOR
MAP BOOK I PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec. Light Sw. OWNER OR LT2�J
COMPENSATION INSURANCEFIRM
First 20 MAIL
(This section need not be completed if the work involved by the Total No. Additional ADDRESS//&,_3
permit is for one hundred dollars($100)or less.)
I certify that in the performance of the work for w his permit CITY °. Tel.No.
is issued, I shall not employ any person in manner so as to PLAN CHECK
become subject to the Workers' Compe Ion Laws. Lighting Fixtures First 20 APPLICANT
Total No. Additional ADDRESS
Date pplicant 15 OR 20A120V BRANCH CIRCUITS
NOTICE TO APP ,ANT: If, after making this Certificate of CITY Tel.No.
Exemption,yoould become subject to the Workers'Compensation 1 TO 10 INCLUSIVE EACH
provision the Labor Code, you must forthwith comply with such 11 TO 40 INCLUSIVE EACH PERMIT
APPLICANT
prov' ' ns or this permit shall be deemed revoked. 41 OR MORE BRANCH CIRCUITS EACH 14-110
A p
LICENSED CONTRACTORS DECLARATION ADDRESS r ��� /��?
1 hereby affirm that I am licensed under provisions of Chapter 9 15 OR 20A,208V TO 277V LIGHTING EACH
(commencing with Section 7000) of Division 3 of the Business and CITY S �L/ Tel.No. ` (�
Professions Code, and my license is in full force and effect. RESIDENTIAL APPLIANCES UP TO 3HP LICENSE OR Ct
r/ �/ 7 /� Power Apparatus&Large Appliances REG.NUMBER r�O 1/-7Class. C/o 0
License Number // `r" 7/ Lic.Class CIO Size&Type HP,KW,KVA,or KVAR DISTRICT NO. r �l PROQESSfD BY �
Up to 3 Incl. )- O c �LG ✓.erLLI
->
Over 3 to 10 Incl. FINAL
Contractor � �� Date Z— DATE
Over 10 to 50 Incl. /
❑ I am exempt under Sec. VALIDATION
P Over 50 to 100 Incl.
Over 100 FINAL
B.&P.C.for this reason BY
Services,Swbd.,MCC&Panelboards
Date: 0-200 Amp.Under 600 V
Signature 201-1000 Amp.Under 600 V
EJ
Over 1000 Amp.or Over 600 V
Exemption for Reg.Maint.Elect.
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Temp.Power Pole&Appurtenances
I hereby affirm that I am exempt from the Contractor's License L w Sign with One Branch Circuit
for the following reason (Section 7031.5, Business and Profes ' ns Additional Sign Branch Circuits
Code):
❑ I, as owner of the property,will do the wor d the structure Misc.Conduits&Conductors - -
is not intended or offered for sale (S Ion 7044, Business Other(See Complete Fee Schedule) , rr
and Professions Code).
CONSTRU N LENDING AGENCY
I hereby affirm that t e is a construction lending agency for the
performance of t work for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total)
Civ. C.)
PLAN CHECKING FEE
Lend Name 2."
PERMIT ISSUING FEE = -
ender's Address
I certify that I have read this application and state that the above TOTAL FEE
information is correct. I agree to comply with all County ordinances
and State laws regulating Electrical wiring, and hereby authorize
representatives o this County nter upon the above-mentioned
property f% tion r SEE REVERSE FOR EXPLANATORY LANGUAGE
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SIG ATURE O APPLICANT OR ENT DATE