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HomeMy Public PortalAbout4956 GLICKMAN AVE_Electrical__ WORKS �MPENSATION DECLARATION 20-0019 DPW 9/89 , I hereby affirm that I a certificate of consent to self insure, 76A663 APPLICON 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..38000 Lab. C.) Policy NO 1020?11t / Company /� _'�'�" FOR APPLICANT TO FILL IN JOB ADDRESS Certified copy is hereby furnished. New Residential Bldgs.&1 &2-Family,Sq.Ft._o Pools EACH NO. FEE$ LOCALITY l � b $� © — Certified copy is filed with the county building inspection _ NEAREST depart ent. ,�f T Multi-family Sq.Ft. CROSS ST. Date _( Applicant r U j1141c, Residential Swimming Pools ASSESSOR /l+ MAP BOOK PAGE PARCEL CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec. Light Sw. OWNER OR COMPENSATION INSURANCE FIRM NAME Z;-,,;FIfSt 20 (This section need not be completed if the work inv Ived by the MAIL Total No. Additional ADDRESS �Q3 :�L �� o permit is for one hundred dollars($100)or less _ I certify that in the performance of the w for which this permit CITY C �" II Tel.No. is issued, I shall not employ any pe n in any manner so as to PLAN CHECK become subject to the Workers' pensation Laws. Lighting Fixtures First 20 APPLICANT Total No. Additional ADDRESS Date Applicant 15 OR 20A,120V BRANCH CIRCUITS NOTICE TO LICANT: If, after making this Certificate of CITY Tel.No. Exemption, u should become subject to the Workers'Compensation 1 TO 10 INCLUSIVE EACH IT provisio of the Labor Code, you must forthwith comply with such 11 TO 40 INCLUSIVE EACH APPLICANT prow ons or this permit shall be deemed revoked. 41 OR MORE BRANCH CIRCUITS EACH /,/C LICENSED CONTRACTORS DECLARATION ADDRESSAV Zed.. AAe_--�1W/ IL 15 OR 20A,208V TO 277V LIGHTING EACH I hereby affirm that I am licensed under provisions of Chapter 9 W C (commencing with Section 7000) of Division 3 of the Business and CITY _ Tel.N ,11 --�. Professions Code, and my license is in full force and effect. RESIDENTIAL APPLIANCES UP TO 3HP LICENSE OR / Power Apparatus&Large Appliances REG.NUMBER �! Class. �;�® 0 Size&Type HP,KW,KVA,or KVAR DISTRICT NO. P CESSED BY License Number Lie.Class jJ ��� Up r 3 incl. G O LU Contractor C��� /+� i�'"' 11lTDate �� Over 3 to 10 Incl. FINAL t1J Over 10 to 50 Incl. �z z❑ �L/C� c'1 am exempt under Sec. Over 50 to 100 Incl. VALIDATION FINAL B.&P.C.for this reason Over 100 BY Services,Swbd.,MCC&Panelbcards 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 DECLARATION , ' I hereby affirm that I am exempt from the Contractor's Lie se Law Sign with One Branch Circuit for the following reason (Section 7031.5, Business rofessions Additional Sign Branch Circuits Code): ❑ I,as owner of the property,will he work and the structure Misc.Conduits&Conductors is not intended or offered sale (Section 7044, Business Other(See Complete Fee Schedule) , and Professions Code) CONS CTION LENDING AGENCY I hereby affirm th ere is a construction lending agency for the -- - performance of a work for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total) C. C.) PLAN CHECKING FEE Len s Name PERMIT ISSUING FEE 17:11 Aj 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 representatives of this Coun to enter upon the above-mentioned property or' s ecti0 s. SEE REVERSE FOR EXPLANATORY LANGUAGE SIGNATURE OF APPLICANT AGENT DATE