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HomeMy Public PortalAbout5002 GLICKMAN AVE_Electrical__ WORKF_ DMPENSATION DECLARATION so-oolvDPW sia7 A PPLI♦ �I®IV FOR ELECTRICAL PERMIT O I hereby affirm have a certificate of consent to self cE eoe� A insure, or a cert..._--- of Workers' Compensation_Insurance, COUNTY OF Lwa ANGELES DEPT. OF PUBLIC WORKS or a certified copy thereof (Sec. 3800, Lab. C.) ��n1 Tom-'-� Policy No Company FOR APPLICANT TO FILL IN JOB � Certified copy is ereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADDRESS certified copy is filed with the county building inspec- 1 &2-Family, Sq. Ft. ��� $ — $ LOCALIT Q Ytion depa tment. Multi-family Sq. Ft. — NEAREST CROSS ST. Date Applicant A/ 11-IC Residential Swimming Pools OWNEROR FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw._ MAILS COMPENSATION INSURANCE ADDRESS S S ��All (This section need not be completed if the work involved by First ti CITY Tel. No. C the permit is for one hundred dollars (51 00)or less. Total No. Additional Jr3 t. . © (j PLAN CHECK I certify that in the performance of the work f ich this APPLICANT permit is issued, I shall not employ any per in any manner so as to become subject to the Work 0mpensation Laws. Lighting Fixtures First 20 ADDRESS Additional Total No. CITY Tel. No. Date A icantFixed Appliances Not Over 1 HP PERMIT PLI NOTICE TO APC : If, after making this Certificate of APPLICATION IV 47 a Exemption, yo should become subject to the Workers' Range— Heater—D.W. — Compensat' provisions of the Labor Code, you must forth- Oven — Dryer —W.M.— ADDRESS 2,0 with cpMply with such provisions or this permit shall be Top — FAU —W.H. — de ed revoked. Hood — Fan —Other— CITY Tel. No.� LICENSED CONTRACTORS DECLARATION LICENSE OR I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. — REG. NUMBER Class. G f v (commencing with Section 7000)of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO. PC O SED BY and Professions Code,and my license is in full force and effect. CL / Size&Type HP, KW, KVA, or KVAR 1 Gj Q 0 License NumberLic. Class a Up to 1 Incl. FINAL ��� Cir TM /� Over 1 to 10 Incl. DATE Z—l7-44zz- VALIDATION M0 Contractor Date Over 10 to 50 Incl. �Z F— ❑ FINAL U I am exempt under Sec. Over 50 to 100 Inc. BY f W B.&P.C. for this reason Over 100 a- Services, ® Services, Swbd., MCC& Ponelboards Z 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 Co actor's License Sign with One Branch Circuit Law for the following reason (Section 7 .5, Business and Additional Sign Branch Circuits Professions Code): ❑ Misc. Conduits&Conductors I, as owner of the prope , will do the work and the structure is not intende r offered for sale(Section 7044, Other (See Complete Fee Schedule)_ Business and Profe 'ons Code). _ __. • ,. __ _ _ _ CONS CTION LENDING AGENCY I hereby affirm at there is a construction lending agency for the perform ce of the work for which this permit is issued PERMIT FEE (Sub-Total) - (Sec. 3097 iv. C.). PLAN CHECKING FEE Len is Name PERMIT ISSUING FEE �f L rider's Address I certify that I have read this application and state that the TOTAL FEE above information is correct. I agree to comply with all County ordinances and State laws regulating Electrical wiring, and hereby authorize representatives of this County to enter upon the abo - ention �rtyor ' pectioSEE REVERSE FOR EXPLANATORY LANGUAGE 1�� es gnatjy of ermitte® Date