HomeMy Public PortalAbout4827 GLICKMAN AVE_Electrical__ 76A663-CE806 5-62 APPLICATION FOR ELECTRICAL PERMIT
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER BUILDING
BUILDING AND SAFETY DIVISION ADDRESS a/ _
JOHN A. LAMBIE, COUNTY ENGINEER
WILLIAM A. JENSEN, SUPT OF BUILDING LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
RECEPT, TOTAL �O, EACH FEE
LIGHT OUTLETS FIRST 20 20 DMALER
/J ADDL / ADDRESS
SWITCH. /� --L OVER 20 .10
LIGHTING --
-T TOTAL F1R5T 20 .20 CITY TEL O.
FIXTURES ADD'L 10 ELECTRICIA
0VgR 20 ��
RANGES CLO.DRYERS WD
TR.HTRS. 1.00 ADRESS /
GARB.D�� STA.COOK 1 CITY_ TE O. �/ v
DISHWASH. AUTO.-WASH. STATE
SPACE HTRS. STA, PP.(V H.P.MAX.) .5O 0 LICENSE NO. �1
MOTORS: OVER NOT OVER H.P. DISTRICTNO. GROUP ZONE PROCESSED BY
O 1 1.00
�Y
J• 1. A -� �c l O✓VCc
1 3 1.50 INSPECTION RECORD
3 S 2.00
B 15 2.50 CL
O
15 50 3.00 V
50 100 5.00 O
SIGNS: NO.TRANS W
NO.LAMPS
CL
SERVICE 0.60OV-NOT OVER 200A 1.00 Z
SERVICE 0.60OV-OVER 200 A. 2.00
SERVICE OVER 600V 5.00
MISC.
PERMIT ISSUING FEE 2.00
SUPPLEMENTARY PERMIT ISSUING FEE 1.00
TOTAL FEE $
IHEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLI ATION APPROVALS DATE INSPECTOR'S SIGNATURE
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CONDUIT
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING _
ELECTRICAL WIRING. WIRING s'
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR17 l� 7
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF FIXTURES
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL P RT POWER
SIGNATURE � UTILITY CO.NOTIFIED
OF PERMITTEE --
FINAL
LIDATION ARTHUR C. VEIT
ocr
MO CASH SUPERVISING ELECTRICAL ENGINEER
2 5 0 1"a' MAR216 2 0 14.10--
WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12-91)
76A663 APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have 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.)
Policy No. Company FOR APPLICANT TO FILL IN ADDRESS L 7
{\f
�U
❑
Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. $ EACH $ FEE LOCALITY
❑ Certified copy is filed with the county building inspection 1 &2-Family,Sq.Ft. _ NEAREST
department. Multi-family Sq.Ft. CROSS ST.
Date Applicant Residential Swimming Pools ASSESSOR
MAP O
PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' WNER OR
COMPENSATION INSURANCE Outlets:Rec.7 Light Sw. + � FIRM NAME 7�L -Lvvw
First 20 ML/
AIL j r�
(This section need not be completed if the work involved by the Total No. Additional ADDRESS 2-7 IJ
permit is for one hundred dollars($100)or less.)
I certify that in the performance of the work for which this permit CITY.: f � Tel.No.
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
' II- (� Total No. "y Additional
ADDRESS
`
Date Applican , RESIDENTIAL APPLIANCES NOT OVER 3 HP.
NOTICE TO APPLICANT: If, after makin this Certificate of CITY Tel.No.
Exemption,you should become subject to the Workers' Compensation OTHER APPLIANCES NOT OVER 3 HP.
PERMIT
rovisions of the Labor Code, ou must forthwith comply with such f)_�,' /:,,
p y p y Power Apparatus&Large Appliances APPLICANT (%U l�G ✓Vt�
provisions or this permit shall be deemed revoked.
LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS10195-C-41-.416
I hereby affirm that I am licensed under provisions of Chapter 9 Over 3 to 10 Incl. CITY yy Tel. o. �' a
(commencing with Section 7000) of Division 3 of the Business and -410//�16 460_;—/ L/
Professions Code, and my license is in full force and effect. Over 10 to 50 Incl. LICENSE OR
Class. }
Over 50 t0 100 Ind. REG.NUMBER& d
Over 100 DISTRICT NO.
License Number GT f�fZ Lic.Class��.. P SED BY
pp Services,Swbd.,MCC&Panelboards V9 ,
Contractor &EI IJ Tr`d � (itShTL- Date 0-399 Amp.Under 600 V NAL
DATE
❑ I am exempt under Sec. 400-1000 Amp.Under 600 V �' i0 VALIDATION C)Over 1000 Amp.or Over 600 V FINAL LL1
B.&P.C.for this reason BRANCH CIRCUIT FEES BY (!)
—Date: (- 15-74i_11 15A,or 20A,120V,Lighting or Recept. Z
Rignature! t Com_ r 7i �^� / 1 To 10 Branch Circuits
l� 11 To 40 Branch Circuits
❑ / 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 DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License Law
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits "
Code):
❑ I, as owner of the property,will do the work and the structure _ Misc.Conduits&Conductors
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule)
and Professions Code). ® f HE ;• s r
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the
performance of the work for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total)
Civ. C.)
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEED C "'
Lender's Address .�
I certify that I have read this application and under penalty of purjury state TOTAL FEE
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
/i__1 T-5 y
SIGNA E OF ERMI DATE