HomeMy Public PortalAbout5016 GLICKMAN AVE_Electrical__ WORKE )MPENSATION DECLARATION 20-0019DPW 9/89
I hereby affirm that a a certificate of consent to self insure,
76A663 APPLIC ION FOR ELECTRICAL PERMIT
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.380[00 Lab. C.) S/QL p
Policy NoV Company >// "C " FOR APPLICANT TO FILL IN JOB /
❑ . - ADDRESS (p
Certified copy,is hereby furnished. New Residential Bldgs.&Pools EACH NO. FEE LOCALITY
Certified co is filed with the count building 1 &2-Family,Sq.Ft.!�// $ — $ 0
copy y g InSpeCtiDn _ NEAREST
depart en. Multi-family Sq.Ft. CROSS ST.
pp �fU //V Residential Swimming Pools ASSESSOR
Date Applicant MAP BOOK
PAGE PARCEL
7
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec. Light Sw. OWNER OR
COMPENSATION INSURANCE FIRM NAME
First 20 MAIL
(This section need not be completed if the work invo d by the Total No. Additional ADDRESS f�3 SZ zI /
permit is for one hundred dollars($100)or less.
I certify that in the performance of the wo or which this permit CITY Sct K_ Tel.No.
is issued, I shall not employ any per in any manner so as t0 PLAN CHECK
become subject to the Workers'C pensation Laws. Lighting Fixtures First 20 APPLICANT
Total No. Additional
ADDRESS
Date Applicant 15 OR 20A,120V BRANCH CIRCUITS
NOTICE TO A (CANT: If, after making this Certificate of CITY Tel.No.
Exemption, should become subject to the Workers'Compensation 1 TO 10 INCLUSIVE EACH J r
P=1.10 1.1 of the Labor Code, ybu must forthwith comply with such 11 TO 40 INCLUSIVE EACH APPLICANT /A L�,
Prov' ons or this permit shall be deemed revoked. 41 OR MORE BRANCH CIRCUITS EACH >_
LICENSED CONTRACTORS DECLARATION ADDRESS
I hereby affirm that I am licensed under provisions of Chapter 9 15 OR 20A,208V TO 277V LIGHTING EACH
(commencing with Section 7000) of Division 3 of the Business and CITY 1 /'–G Tel.N . J+F? r�
Professions Cade, and my license is in full force and effect. RESIDENTIAL APPLIANCES UP TO 3HP LICENSE OR C[
/ Power Apparatus&Large Appliances REG.NUMBER class. e(() 0
LicenseNumber % / Lie.Class t��0 Size&Type HP,KW,KVA,or KVAR DISTRICT NO. PROLE SED BY U
r
Up to 3 Incl. LLI��� 4��.;dr �
�r�` a Over 3 t0 10 Incl. FINAL
Contractor[/>i g �/d-,C�C&, � Date DATE Lo
Over 10 to 50 Incl. Z
F]
I am exempt under Sec. Over 50 to 100 Incl. 17i VALIDATION
Over 100 FINAL
B.&P.C.for this reason BY
Services,Swbd.,MCC&Panelboards
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 Contractor's License Law :iI•: I ..
for the following reason (Section 7031.5, Business and fofessions Additional Sign Branch Circuits T
Code):
❑ I,as owner of the property,will do the ork and the structure Misc.Conduits&Conductors
is not intended or offered for s Section 7044, Business Other(See Complete Fee Schedule)
and Professions Code).
CONS
N LENDING AGENCY
I hereby affirm that th is a construction lending agency for the
performance of th ork for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total)
Civ. C.)
PLAN CHECKING FEE
Lender' ame _
PERMIT ISSUING FEE
Lender's Address
I certify that I have read this application and state that the above TOTAL FEE
information is correct. I agree to comply with all County ordinances
and State laws regulating Electrical wiring, and hereby authorize
representatives of this Cou "upon the above-mentioned
property_Wp ito p ses // �'� SEE REVERSE FOR EXPLANATORY LANGUAGE
SI ATU AP ICANT AGENT �Y' DATE