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HomeMy Public PortalAbout5004 GLICKMAN AVE_Electrical__ WORK OMPENSATION DECLARATION 20-0019DPW(12-91) 76A663 APPLIC 'ION FOR ELECTRICAL PERMIT I hereby affirm th ve a certificate of consent to self insure, 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.) _ n ' Policy No. 2 '--I Company �1-z z- iLli FOR APPLICANT TO FILL IN JOB �' '�� � ( � ADDRESS i L:L'4 C'`-7 L f A 1,C-., ❑ Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE LOCALITY I $ $Ft Sq. . _ I Certified copy is filed with the county building inspection 1&2-Family, NEAREST department. Multi-family Sq.Ft. CROSS ST. F 3•—i Z a 1 F� Residential Swimming Pools ASSESSOR Date Applicant MAP BOOK \ PAGE PARCEL CERTIFICATE OF EXEMPTION FRO WORKERS' OWNEROR COMPENSATION INSURA CE Outlets:Rea_Light SW. FIRM NAME , ! (t C C � to 1-Z4— (This 20 MAIL J (This section need not be completed if the work involved by the ADDRESSCO -Zr_�G. F-Lk s.- permit is for one hundred dollars($100)or less.) Total No. Additional L S =1(3��) I certify that in the performance of the work for which this permit CITY �6 �lm1�Dd-�� Tel.No.�l?� ISnt is issued, I shall not employ any person in any manner so as to PLAN CHECK become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 APPLICANT Total No. Additional ADDRESS Date Applicant RESIDENTIAL APPLIANCES NOT OVER 3 HP. NOTICE TO APPLICANT: If, after making this Certificate of CITY Tel.No. Exemption,you should become subject to the Workers'Compensation OTHER APPLIANCES NOT OVER 3 HP. _ provisions of the Labor Code, you must forthwith comply with SUCK PERMIT APPLICANT C�t'•�t�i�G�D� provisions or this permit shall be deemed revoked. Power Apparatus&Large Appliances LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS >< J S �A I hereby affirm that'I am licensed under provisions of Chapter 9 Over 3 to 10 Incl. f� �'F (commencing ) CITY �. blLil Tel.No. )1�1f6Z commencin with Section 7000 of Division 3 of the Business and G; Professions Code,and my license is in full force and effect. Over 10 to 50 Incl. LICENSE ORClass. Over 50 to 100 Incl. REG.NUMBER C 7 13 d� 7 ^7 Over 100 DISTRICT NO. PRO ES D BY License Number ✓ t r Lic.Class � \\ Services,Swbd.,MC��C&Pan I cards �e�'��•1�1���z� OC Contractor T(-X C,f��'I-' I Date ( � � 0-399 Afnp. nder 60 V ``�" © FINAL 0 DATE ❑ 400-1000 Amp.Under 600 V t' (� I am exempt under Sec. 7� �'^ VALIDATION LU 1000 Amp.or Over 600 V FINAL B.&P.C.for this reason BRANCH CIRCUIT FEES BY (n Date: 15A,or 20A,120V,Lighting or Recept. 1 To 10 Branch Circuits Signature 11 To 40 Branch Circuits El 41 Or More Branch Circuits Exemption for Reg. Maint.Elect. 15A,20A,208V To 277V Lighting Br.Circuits SINGLE FAMILY Temp.Power Pole&Appurtenances HOME OWNER-BUILDER DECLARATIONE 1L I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit (=sv(.,T.117 for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits it f Code): 330 El1,as owner of the property,will do the work and the structure Misc.Conduits&Conductors 1 ITEMS is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) ® TOTAL ITAL _s'? 55 and Professions Code). CONSTRUCTION LENDING AGENCY CHECK. 59.5..' 1 hereby affirm that there is a construction lending agency for the CHANGE .00 performance of the work for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total) o Civ. C.) PLAN CHECKING FEEii" I-+� i0 �,:.{_i Lender's Name PERMIT ISSUING FEE p2 fj 05485 L AN1i la_li Lender's Address r, I certify that I have read this application and under penalty of purjury state TOTAL FEE r i that the 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 above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE // _1.3 — � 2 SIGNATURE OF,7AMITTEE DATE