HomeMy Public PortalAbout5012 GLICKMAN AVE_Electrical__ WORK OMPENSATION DECLARATION 76A669oFw9 67 APPLI< PION FOR ELECTRICAL PERMIT O
I hereby affirm I have a certificate of consent to self CEso6G
insure, or a cer'....__...; of Workers' Compensation Insurance, COUNTY OE Ldp ANGELES DEPT. OF PUBLIC WORKS
or a certified copy thereof (Sec. 3800, Lob. C.)
Policy No Company 514 FOR APPLICANT TO FILL IN JOB
❑�Certified copy s hereby furnished.' New Residential Bldgs. & Pools EACH NO. FEE ADDRESS :�.
®Certified copy is filed with the county building inspec- 1 &2-Family, Sq. Ft.1100-50 $ 6 — $ 7O LOCALITY
LLLL8888CCCCJJJJ tion department. Multi-family Sq. Ft. — NEAREST
� tc� `iv'` Residential Swimming Pools OWNERCROSS S
T.
Date Applicant
OR
r _
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw._ MAIL /�t ,/'
COMPENSATION INSURANCE ADDRESS
(This section need not be completed if the work involved by Total No. Additional First 20 onal CITY�`„ Tel. No. • ” "
the permit is for one hundred dollars ($100)or les PLAN CHECK
I certify that in the performance of the wor or which this APPLICANT
permit is issued, I shall note
mploy any on in any manner
so as to become subject to the Wor on
Laws. Lighting Fixtures First 20 ADDRESS
Additional
Total No. CITY Tel. No.
Date Ap cant Fixed Appliances Not Over 1 HP PERMIT /V
r d
NOTICE TO APPLICA . If, after making this Certificate of APPLICATION tom" F (+V C-
Exemption, you ould become subject to the Workers' Range— Heater—D.W. —
Compensatio rovisions of the Labor Code, you must forth- Oven — Dryer —W.M.— ADDRESS /,Poe r ler ,�V� 10/e
with com with such provisions or this permit shall be Top — FAU —W.H. —
deem revoked., Hood — Fan —Other— CITY Tel. No. 3�
LICENSED CONTRACTORS DECLARATION LICENSE OR / 4® Class.
I hereby affirm that I am licensed under provisions of Chapter 9 J�
Disp. Room Air Cond. REG. NUMBER
(commencing with Section 7000)of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO. M01 D BY dand Professions Code,and my license is in full force and effect.
License NumberSize&Type HP, KW, KVA, or KVAR �G -�� O
Lic. Class �j Up to 1 Incl. FINAL U
Contractor 6/Olf'i����Z1�in( a Over 1 to 10 Incl. DATE VALIDATION 0
Date Over 10 to 50 Incl. G d l-_
F]
I am exempt under Sec. Over 50 to 100 Inc. U
gy
B.&P.C. for this reason Over 100 d
Services, Swbd., MCC & Panelboards ZZ
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 Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contrac s License
Law for the following reason (Section 7031. usiness and Additional Sign Branch Circuits
Professions Code): -
❑ I, as owner of the propert ill do the work and the Misc. Conduits&Conductors
structure is not intended offered for sale(Section 7044, Other (See Complete Fee Schedule)_ '
Business and Profess' s Code). –
CONST CTION LENDING AGENCY r
I hereby affirm t t there is a construction lending agency for
the performa e of the work for which this permit is issued PERMIT FEE (Sub-Total)
(Sec. 3097 iv. C.).
PLAN CHECKING FEE
Lend ',Name
PERMIT ISSUING FEE
Lender'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 tLielounty to enter upon
the abov ne r y fo ' ection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signatu a mittee Date