HomeMy Public PortalAbout4952 GLICKMAN AVE_Electrical__ WOF COMPENSATION DECLARATION 20-0019 DPW 9/69
I I hereby affirm t ave a certificate of consent to self insure, 76A663 APPLI TION FOR ELECTRICAL PERMIT
i 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. CompanyT, ! T FOR APPLICANT TO FILL IN JOB
ADDRESS
Certified copy is ereby furnished. New Residential Bldgs.&Pools EACH NO. FEE
LOCALITY
Certified copy is filed with the county building inspection 1 &2-Family,Sq.Ft.---� $' $ NEAREST
i
depart ntt oc
Multi-family Sq.Ft. CROSS ST.
Date 6 L L Applicant /V eResidential Swimming Pools ASSESSOR
MAP BOOK PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec._Light Sw. OWNER
RM NAMErlTi}C
COMPENSATION INSURANCE
(This section need not be completed if the work , olved by the First 20 MAIL
permit is for one hundred dollars($100)or s.)
Total No. Additional ADDRESS S �sG'
I certify that in the performance of t ork for which this permit CITY j T.I.No.
is issued, I shall not employ a erson in any manner so as to PLAN CHECK'
become subject to the Wor Compensation Laws. Lighting Fixtures First 20 APPLICANT
Total No. Additional
ADDRESS
Date Applicant 15 OR 20A,120V BRANCH CIRCUITS
NOTICE APPLICANT: If, after making this Certificate of CITY Tel.No.
Exem 'on,you should become subject to the Workers'Compensation 1 TO 10 INCLUSIVE EACH
r Iss s of the Labor Code, you must forthwith comply with such 11 TO 40 INCLUSIVE EACH PERMIT
P Y P Y APPLICANT
�vislons or this permit shall be deemed revoked. 41 OR MORE BRANCH CIRCUITS EACH
LICENSED CONTRACTORS DECLARATION ADDRESS
I hereby affirm that 1 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 Tel.Ndy �LQ_ 0
Professions Code, and my license is in full force and effect. RESIDENTIAL APPLIANCES UP TO 3HP LICENSE OR rc
y� Power Apparatus&Large Appliances REG.NUMBER s-�® class. C
License Number �r( � `Y Lic.Class %[� Size&Type HP,KW,KVA,or KVAR DISTRICT NO. PROCES ED BY
Up to 3 Incl .C/ w
Contractor Date ! 7' Over 3 to 10 Incl. FINDATE CO
Over 10 to 50 Incl. -(3/? Z
F-1I am exempt under Sec. Over 50 to 100 Incl. 7i VALIDATION
Over 100 FINAL
B.&P.C.for this reason BY e,c /
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 FAMILY Temp.Power Pole&Appurtenances
HOME OWNER-BUILDER DECLAR Sign with One Branch Circuit
I hereby affirm that I am exempt from the C ractor's License Law
for the following reason (Section 7031. , usiness and Professions Additional Sign Branch Circuits
Code):
:_:•:
❑ ,....:
I,as owner of the p erty,will do the work and the structure Misc.Conduits&Conductors
is not intended offered for sale (Section 7044, Business Other(See Complete Fee Schedule)
and Profess' s Code).
CONSTRUCTION LENDING AGENCY
I hereby Irm that there is a construction lending agency for the -
perfor nce of the work for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total)
Civ. .)
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE
Lender'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
1 representatives of this CL ty to enter upon the above-mentioned
I� proper er i na �— SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE OF APPLICArqlr OR AGENT DATE
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