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HomeMy Public PortalAbout5010 GLICKMAN AVE_Electrical__ WORKI CIMPENSATION DECLARATION 20-0019 DPW 3/87 76A663 APPLIC 'ICON FOR ELECTRICAL PERMIT I hereby affirm have a certificate of consent to self cE-e06c insure, or a cert...,-.-, of Workers' Compensation Insurance, COUNTY OF a.a ANGELES DEPT. OF PUBLIC WORKS or a certified copy thereof (Sec. 3800, Lab.-C.) Policy No. Company � �t�. ys FOR APPLICANT TO FILL IN JOB ❑Ce tified copy i hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADDRESS copy y g p y q $ ,42% _ LOCALITY 'rt co is filed with the count building inspec- 1 &2-Famil S Ft. tion department. Multi-family Sq. Ft. NEAREST �j CROSS ST. Date T �p Applicant Residential Swimming Pools OWNER OR FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' MAIL , Outlets: Rec Light Sw._ ADDRESS ��l? s. S ,!1'Xidt� 6/COMPENSATION INSURANCE First 20 tThis section need not be completed if the work!rival CITY 9 Tel. No. he permit is for one hundred dollars ($100)or I Y Total No. Additional �� PLAN CHECK I certify that in the performance of thew or which this APPLICANT permit is issued, I shall not employ an rson in any manner Lighting Fixtures First 20 ADDRESS so as to.become subject to the W ers'Compensation Laws. Additional Total No. CITY Tel. No. Date �If .fter Fixed Appliances Not Over 1 HP PERMIT NOTICE TO APPLI making this Certificate of APPLICATION // ,Q JIMIC-1 E>d. ed tion, should become subject to the Workers' Range— Heater—D.W. — s n provisions of the Labor Code, you must forth- Oven — Dryer —W.M.— ADDRESS k'� �,LL �j ply with such provisions or this permit shall be Top — FAU —W.H. — revoked. Hood — Fan —Other— CITY �' / : Tel. No LICENSED CONTRACTORS DECLARATION LICENSE OR Disp. — Room Air Cond. — �Q Class. LZZ I hereby affirm that I am licensed under provisions of Chapter 9 REG. NUMBER (commencing with Section 7000)of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO. P OC SSED BY and Professions Code,and my license is in full force and effect. / J Size&Type HP, KW, KVA, or KVAR ��/ . J,iG� 0 License Number :1V1Py 7 Lic. Class / Up to 1 Incl. FINAL 0 �'IIi J /�� Over 1 to 10 Incl. DATE y VALIDATION IM Contractor �s ate Over 10 to 50 Incl. L. I— ❑ FINAL _ 0 I am exempt under Sec. Over 50 to 100 Inc. BY W B.&P.C. for this reason Over 100 d Z Services, Swbd., MCC& Panelboards Date: Z 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 Temp. Power Pole &Appurtenances HOME OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contracto' License Sign with One Branch Circuit Law for the following reason (Section 7031.5, siness and Additional Sign Branch Circuits Professions Code): ❑ I, as owner of the property, w' do the work and the Misc. Conduits&Conductors structure is not intended or o red for sale(Section 7044, Other (See Complete Fee Schedule)_ Business and Profession ode). CONSTRU N LENDING AGENCY I hereby affirm that ere is a construction lending agency for the performancpoli5if the work for which this permit is issued PERMIT FEE (Sub-Total) ` (Sec. 3097, C.). PLAN CHECKING FEE Lend s Name PERMIT ISSUING FEE `•',f _ nder's Addressc- I certify that 1 have read this application and state that the I TOTAL FEE above information is correct. I agree to comply with all County ordinances and State laws regulating Electrical wiring, and hereby authorize represent t' of this County to enter upon the abo - lone pr e for ' pe ion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE A!?� ©5 igna a ermitt Date