HomeMy Public PortalAbout4960 GLICKMAN AVE_Electrical__ WORKE IMPENSATION DECLARATION 20-0019 DPW 9/89
I hereby affirm that a certificate of consent to self insure, 76A663 APPLIC ON 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.)
Policy o.
Company NCom an d FOR APPLICANT TO FILL IN JOB
ADDRESS
El
Certified copy is hereby furnished. New Residential Bldgs.&Pool EACH NO. FEE LOCALITY
1&2-Family,Sq.Ft.-� $i — $
Certified copy is filed with the county building inspection _ NEAREST
d t. /JJ Multi-family Sq.Ft. CROSS ST.
Date ®� Applicant r _ Residential Swimming Pools ASSESSOR
PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec._Light SW. FlRM NAME -
WNER OR
COMPENSATION INSURANCE
First 20 MAIL
(This section need not be completed if the work invol by the Total No. Additional ADDRESS .S
permit is for one hundred dollars($100)or less.)
I certify that in the performance of the wo which this permit CITY Tel.No.�
CL a
is issued, I shall not employ any pe in r any manner so as to PLAN CHECK
become subject to the Workerspensation Laws. Lighting Fixtures First 20 APPLICANT
Total No. Additional ADDRESS
Date Applicant 15 OR 20A,120V BRANCH CIRCUITS
NOTICE T PPLICANT:,If, after making this Certificate of CITY Tel.No.
ExeIT
mp' ,you should become subject to the Workers'Compensation 1 TO 10 INCLUSIVE EACH
pro ' Ions of the Labor Code, you must forthwith comply with such 11 TO 40 INCLUSIVE EACH APPLICANT
visions or this permit shall be deemed revoked. 41 OR MORE BRANCH CIRCUITS EACH `
LICENSED CONTRACTORS DECLARATION ADDRESSCL
I hereby affirm that I am licensed under provisions of Chapter 9 15 OR 20A,208V TO 277V LIGHTING EACH ! CL
(commencing with Section 7000) of Division 3 of the Business and CITY-. 114CC) Tel.No. �S
Professions Code,and my license is in full force and effect. RESIDENTIAL APPLIANCES UP TO 3HP LICENSE ORclass
�:/a
Power Apparatus&Large Appliances REG.NUMBER . C/o
l 0
�'j Size&Type HP,KW,KVA,or KVAR DISTRICT NO. PROryyE�S�EID BY I®
License Number Lic.Class C%C �
Up to 3 Incl. �
�^ /Opp 4//6�Q� Over 3 to 10 Incl. FINALDATE U)
Contractor f dLL9-7`P ! / r
❑ .� Date Over 10 t0 50 Incl. DATE �
I am exempt under Sec. Over 50 to 100 Incl. 2- -Z 7— Z VALIDATION
B.&P.C.for this reason
Over 100 BWAL
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 µ
HOME OWNER-BUILDER DECLARATION/ Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractqp`s License Law
for the following reason (Section 7031.5, Busin and Professions Additional Sign Branch Circuits
Code):
,••;
❑ I,as owner of the property, do the work and the structure Misc.Conduits&Conductors
is not intended or offer for sale (Section 7044, Business Other(See Complete Fee Schedule)
Zaffirmt
s Co
UCTION LENDING AGENCY
here is a construction lending agency for theperk for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total)
CiPLAN CHECKING FEE rfj _.._• _� ...
PERMIT ISSUING FEE v/
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 i
this C lsty to ter upon the above-mentioned
propert .f "opurp s SEE REVERSE FOR EXPLANATORY LANGUAGE
IGNAT1,05-ar-APPLPANT OR AGENT DATE