Loading...
HomeMy Public PortalAbout5008 GLICKMAN AVE_Electrical__ WORK OMPENSATION DECLARATION 76A663DPW3/87 APPLI, PION FOR ELECTRICAL PERMIT O I hereby affirm I have a certificate of consent to self CE-806G insure, or a cer...... -, of Workers' Compensation Insurance, COUNTY OF LvS ANGELES DEPT. OF PUBLIC WORKS or a certified copy thereof (Sec. 3800, Lab. C. Policy No " " Company FOR APPLICANT TO FILL IN JOB ❑ 's Certified copy hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADDRESS ��� i l LOCALIT $ Certified copy is filed with the county building inspec- 1 &2-Family, Sq. Ft.�9G'�c�� % _ $ �� O e_. tion ctment. Multi-family Sq. Ft. NEARESCROSS ST. Date Applicants -� Residential Swimming Pools OWNER OR ^ FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' MAIL / p COMPENSATION INSURANCE Outlets: Rec Light Sw._ ADDRESS c � (This section need not be completed if the work involved by Total No, First 20 Additional CITY�-X7�2 f) Tel. No. the permit is for one hundred dollars ($100)or les ) PLAN CHECK I certify that in the performance of the wor r which 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 icanI Fixed Appliances Not Over 1 HP PERMIT NOTICE TO APPLIC If, after making this Certificate of APPLICATION j�L/ lArC Exemption, yo should become subject to the Workers' Range— Heater—D.W. — Compensati provisions of the Labor Code, you must forth- Oven — Dryer —W.M.— ADDRESS 9 `!� with co y with such provisions or this permit shall be Top — FAU —W.H. — �A dee revoked. Hood — Fan —Other— CITY S' G Nld4 Tel. No.2/s� 6 IS. LICENSED CONTRACTORS DECLARATION LICENSE OR Disp. — Room Air Cond. REG. NUMBER �L] Class. �'fQ I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000)of Division 3 of the Business Power Apparatus &Large Appliances DISTRICT NO. POC/SED BY ffa and Professions Code,and my license is in full force and effect. Size &Type HP, KW, KVA, or KVAR :J ���� O License Number Lic. Class Up To 1 Incl. FINAL U DATE Ir �j / Over 1 to 10 Incl. �d VALIDATION Contractor C/dr�e:(��z�� Date Over 10 to 50 Incl. ` ! O ❑ FINAL U I am exempt under Sec. Over 50 to 100 Inc. BY W B.&P.C. for this reason Over 100 Il Services, Swbd., MCC& Panelboards ® Z Date: � 0-200 Amp. Under 600 V Signature 201 - 1000 Amp. Under 600 V ❑ Exemption for Reg. Maint. Elect. Over 1000 Amp. or Over 600 V SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Temp. Power Pole &Appurtenances I hereby affirm that I am exempt from the Contr or's License Sign with One Branch Circuit Law for the following reason (Section 703 . Business and Additional Sign Branch Circuits Professions Code): ❑ I, as owner of the propert will do the work and the Misc. Conduits &Conductors structure is not intended offered for sale(Section 7044, Other (See Complete Fee Schedule)_ _0 Business and Profess' s Code). CONST TION LENDING AGENCY - - Zperforma t there is a construction lending agency for e of the work for which this permit is issued PERMIT FEE (Sub-Total) ��i G. C.). PLAN CHECKING FEEPERMIT ISSUING FEEess I certify that I have read this application and state that the TOTAL FEE j 7 4- above information is correct. I agree to comply with all County ordinances and State laws regulating Electrical wiring, and hereby authorize re motives of this County to enter upon the ab do pro rt r i spection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Sig re �erml ee DaTe �`l ©s