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HomeMy Public PortalAbout4962 GLICKMAN AVE_Electrical__ WORK, OMPENSATION DECLARATION 9DPW 3/87 76A663 APPLIC 'ION FOR ELECTRICAL PERMIT O 76A66 I hereby affirm have a certificate of consent to self CE-806G insure, or a cert..._..... of Workers' Compensation Insurance, COUNTY OF L%ja ANGELES DEPT. OF PUBLIC WORKS or a certified copy thereof (Sec. 3800, Lab. C,.))) Policy No.4 2X4 a04 Company 56�"��6FOR APPLICANT TO FILL IN- JOB `� y ❑Certified copy is hereby furnished. New Residential Bldgs. &Pools EACH NO. FEE ADDRESSLG�.CiL- L — $ LOCALITY P. �' •y-�� j�Certified copy is filed with the county building inspec- 1 &2-Family, Sq. Ft. A71-21 $� _ N'ff G�Gt� tion department. Multi-family Sq. Ft. NEAREST CROSS_?� 1�� Residential Swimming Pools OWNERSOR y' Date —Applicant - / FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' MAIL Outlets: Rec Light Sw.— s COMPENSATION INSURANCE f ADDRESS lC2t This section need not be completed if the woA�lnvolkd'b First 20 CITY Tel. No.the permit n for one hundred dollars (the Y Total No. Additional Z,, I'PLAN CHECK I certify that in the performance of the wor this APPLICANT permit is issued, I shall not employ any on in any manner Lighting Fixtures First 20 ADDRESS so as to become subject to the Wor s'Compensation Laws. Additional Total No. CITY Tel. No. Date �icant Fixed Appliances Not Over 1 HP PERMIT NOTICE TO APPLIC If, after making this Certificate of APPLICATION �� Exemption, yo should become subject to the Workers' Range— Heater—D.W. — Compensa ' provisions of the Labor Code, you must forth- Oven Dryer —W.M.— ADDRESS 4�� IV � with c ply with such provisions or this permit shall be Top FAU —W.H. — de ed revoked. Hood Fan —Other— CITY G a Tel. No � LICENSED CONTRACTORS DECLARATION LICENSE OR Disp. Room Air Cond. lass. I hereby affirm that I am licensed under provisions of Chapter 9 REG. NUMBER .�Q �d (commencing with Section 7000)of Division 3 of the Business Power Apparatus&Large Appliances DISTRICT NO. PROCESSED BY a and Professions Code,and m license is in full force and effect. �J /� y Size &Type HP, KW, KVA, or KVAR �T+©J 0 License Number `sm/�77 Lic. Classes Up to 1 Incl. FINAL U > Over 1 to 10 Incl. DATE Contractor �!� a ���'%L6� �pDate�� —�� ,� VALIDATION e 0 F] Over 10 to 50 Incl. FINAL U I am exempt under Sec. Over 50 to 100 Inc. BY UU B.&P.C. for this reason Over 100 0- Z Date: Services, Swbd., MCC& Ponelboards ® Z 0-200 Amp. Under 600 V Signature 201 - 1000 Amp. Under 600 V ❑ Over 1000 Amp. or Over 600 V � Exemption for Reg. Mai . Elect. Zowner I E FAMILY Temp. Power Pole &Appurtenances ME OW R-BUILDER DECLARATION I hth am exempt from the Contractor's License Sign with One Branch Circuit Lal wing reason (Section 7031.5, Business and Additional Sign Branch Circuits I Prde): ❑ er of the property, will do`the work and theMisc. Conduits 8Conductors s not intended or offeredfor sale(Section 7044, Other (See Complete Fee Schedule)—nd Professions Cdde). CONSTR�U�CTI N LENDING AGENCY - - - I hereby affirm iha Liere is a construction lending agency for -• A the performanc of the work for which this permit is issued PERMIT FEE (Sub-Total) s:,....._._ (Sec. 3097, C.). PLAN CHECKING FEE Lende s Name _ PERMIT ISSUING FEE Lender's Address I I certify that I have read this application and state that the I TOTAL FEE above information is correct. I agree to comply with all County t ordinances and State laws regulating Electrical wiring, and hereby authorize representativ of thi County to enter upon the above-me eo y o section purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature Permitt Date