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HomeMy Public PortalAbout4840 GLICKMAN AVE_Electrical__ 'WORKERS' COMPENSATION DECLARATION20-0019 DPW 3/87 APPLICATION FOR ELECTRICAL PERMIT O ' • I hereby affirm thgt I have a certificate of consent to self 76A663 ce-eoeG insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS or a certified copy thereof (Sec. 3800, Lob. C.) Policy No. OS v`� Company FOR APPLICANT TO FILL IN JOB j f Q ❑Certified'co is hereby furnished. EACH NO. FEE ADDRESS Lf LJ py y New Residential Bldgs. & Pools 1 &2-Famil S Ft. $,G — $ �/' LOCALITY b!y 1= ❑Certified copy is filed with the county building inspec- y, q• IV � _ K?e 74 tion department. Multi-family Sq. Ft. NEAREST 74 Date A ` : �'� pp licant L Oiy .� LLQ Residential Swimming Pools OWNERSOR ; FIRM NAME• - p f /It�IPU/V CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw._ MAIL COMPENSATION INSURANCE ADDRESS Ilea _9_ r �L #f1 First 20 (This section need not be completed if the work involved by Total No. Additional ICITY�� ��'�� /Z� Tel. No. the permit is for one hundred dollars ($100)or less.) PLAN CHECK I certify that in the performance of the work for which this APPLICANT permit is issued, I shall not employ any person in any manner Lighting Fixtures First 20 ADDRESS so as to become subject to the Workers'Compensation Laws. Additional Total No. CITY Tel. No. Date Applicant Fixed Appliances Not Over 1 HP PERMIT NOTICE TO APPLICANT: 1f, after making this Certificate of APPLICATION Lzlr ,JyIA L� C Exemption, you should become subject to the Workers' Range— Heater—D.W. — Compensation provisions of the Labor Code, you must forth- Oven — Dryer —W.M.— ADDRESS l.y.• 1105 with comply with such provisions or this permit shall be Top — FAU —W.H. — I deemed revoked. Hood — Fan —Other— CIT�5ui,J 0-7 Tel. No. LICENSED CONTRACTORS DECLARATION LICENSE OR Disp. — Room Air Cond. — 2 5 Clo 1 hereby affirm that I am licensed under provisions of Chapter 9 REG. NUMBER / ass. C% (commencing with Section 7000)of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO. P - SSED BY a and Professions Code,and my license is in full force and effect. � O Size &Type HP, KW, KVA, or KVAR Ga U License Number- r S Lic. Class C/ Up to 1 Incl. FINAL DATE �jr�� Over 1 to 10 Incl. // VALIDATION O Contractor �O� f�Lt/ 4/7—,-Date °L '2— Over 10 to 50 Incl. FINAL ` f U ElI am exempt under Sec. Over 50 to 100 Inc. BY /j / �j��i W B.&P.C. for this reason Over 100 Date: Services, Swbd., MCC& Ponelboards ® Z Z 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 I hereby affirm that I am exempt from the Contractor's License Sign with One Branch Circuit — Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits Professions Code): Misc. Conduits&Conductors s Other (See Complete Fee Schedule)— IJas owner of the property, will do the work and the l structure is not intended or offered for sale(Section 7044, ' Business and Professions Code). I 2v 0 CONSTRUCTION LENDING AGENCY -- I hereby affirm that there is a construction lending agency for i H L ' " `"r' u .. the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) r-- Lj I;E (Sec. 3097, Civ. C.). H PLAN CHECKING FEE Lender's Name PERMIT ISSUING FEE I `iG0 i-1004-11 1_2 €`f Lender's Address I certify that I have read this application and state that the TOTAL FEE -ao. dj lzi; 1 i H. 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.�3 SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee —T Da et "WORKERS' COMPENSATION DECLARATION C-663 10/81 APPLICATION FOR ELECTRICAL e ECTRICA PERMIT � • I hereby.affirm that I have'a certificate of consent to self insure, CE-806G r O.i 1 fl {� fl L f1�1/� or.a.certilicate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY copy thereof(Sec. 3800,Lab.:C.) Policy No. Company FOR APPLICANT TO FILL IN JOB ❑ p �� � y `� L lGK 4 Iv` Certified•copy is hereby furnished. New Residential Bldgs.&Pools EACH NO. FEE ADDRESS _4 Y $ LOCALITY L 15,M L,- G1 l Ft S il Famy, q. . $ — Certified copy is filed with the county building inspection 1 & 2- _ NEAREST department. Multi-family Sq.Ft. CROSS ST. Uj2-0 S1-\ Date Applicant Residential Swimming Pools OWNER OR 7� FIRM NAME �G( ✓�� CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec Light Sw. MAIL COMPENSATION INSURANCE ADDRESS .17Z vu r-r& (This section need not be completed if the work involved by the First 20 CITY Tel.No. �� 7 ` permit is for one hundred dollars($100)or less.) Total No. Additional CC'/?/a� SUS :Z 2f I certifythat in the performance the for this it PLAN CHECK pormance oe woror wpermAPPLICANT is issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS Additional j Total No. CITY Tel.No. Date ( d Applicant Fixed Appliances Not Over 1 HP PERMIT NOTICE TO APPLICANT: If, after ng this Certificate of APPLICANT Range_ Heater_ D.W. CX Ta` CO!—JIM CO Exemption,you should become subject the Workers'Compensation — provisions of the Labor Code, you must forthwith comply with such Oven — Dryer _ W.M._ ADDRESS � 3 5Aii—J G).f^j P—fO L j3LVl 1� provisions or this permit shall be deemed revoked. Top — FAU _ W.H. _ / LICENSED CONTRACTORS DECLARATION Hood Fan Other_ CITY !�j fJ C�/%�gpj e L_ Tel.No. :4640o I hereby affirm that I am licensed under provisions of Chapter 9 Dis — Room Air Cond. LICENSE OR �� Class. (commencing with Section 7000) of Division 3 of the Business and p REG.NUMBER Professions Code,and my license is in full force and effect. .DISTRICT NOPROCESSED BY Power Apparatus&Large Appliances p Size&Type HP,KW,KVA,or KVAR ��c9 �G U License Number ,J 7V T7 T Lic.Class Up to 1 Incl. FINAL p q Over 1 to 10 Incl. DATE (,' `/ 1 VALIDATION Contractor Date �a �/ / Over 10 to 50 Incl. ( 1 0 ❑ FINAL I am exe under Sec. 17— Over 50 to 100 Inc. BY W B.&P.C.for this reason Over 100 ✓ U) Services,Swbd.,MCC&Panelboards ® Z Date: 0-200 Amp.Under 600 V Signature 201 - 1000 Amp.Under 600 V ❑ f/ Exemption for Reg.Maint.Elect. Over 1000 Amp.or Over 600 V SINGLE FAMILY Temp.Power Pole&Appurtenances e a 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 Si = tea Code): s sib- ; ElI,as owner of the property,will do the work and the structure Misc.Conduits& Conductors i ����;_; is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) and Professions Code). ® TO FOIL L _3 OCII CONSTRUCTION LENDING AGENCY CECIL( _ t) j I hereby affirm that there is a construction lending agency for the � t_IE- performance of the work for which this permit is issued(Sec.3097, PERMIT FEE (Sub-Total) 5 (" [iiNG , ,_ LU Civ.C.). PLAN CHECKING FEE Lender's Name _)L`Ji" S_{i i' i�;r ,.I i ! € 1 l PERMIT ISSUING FEE o 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 County to enter upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE `o -j—f o Signatur ermittee Date WORKERS' COMPENSATION DECLARATION 20-001 76AM3 DPW 3187 APPLICATION FOR ELECTRICAL PERMIT O I hereby affirm that I have a certificate of consent to self -ce-ao6G insure, or a"certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS or a certified copy thereof-(Sec. 3800, Lab. C.) - Po.kcy No. G��3 CompanyFOR APPLICANT TO FILL IN JOB ❑Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH rNO. FEE ADDRESS F-1 Certified copy is filed with the county building inspec- 1 &2-Family, Sq. Ft. �9 $ $ LOCALITY tion department. Multi-family Sq. Ft. NEAREST / N Z Z� CROSS ST. Date "� Applicant 7� A O �'�� Z OWNER OR PP ,L_� Residential Swimming Pools FIRM NAME r0 u N�N CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw._ MAIL ? S COMPENSATION INSURANCE ADDRESS O_> S Ue;-k4 rl L- First 20 (This section need not be completed if the work involved by Total No. Additional CITY z��IJ'fV 4�1,„ r� Tel. No. the permit is for one hundred dollars ($100)or less.) PLAN CHECK I certify that in the performance of the work for which this APPLICANT permit is issued, I shall not employ any person in any manner Lighting Fixtures First 20 ADDRESS so as to become subject to the Workers'Compensation Laws. Additional Total No. CITY Tel. No. Date Applicant Fixed Appliances Not Over 1 HP PERMIT NOTICE TO APPLICANT: If, after making this Certificate of APPLICATION /a/'-- Exemption, you should become subject to the Workers' Range— Heater—D.W. — Compensation provisions of the Labor Code, you must forth- Oven — Dryer —W.M.— ADDRESS 2�TJ "1211f with comply with such provisions or this permit shall be Top — FAU —W.H. — deemed revoked. Hood — Fan —Other— CITY �Z Tel. No. �.g f�/ LICENSED CONTRACTORS DECLARATION LICENSE OR Disp. — Room Air Cond. Class. C/U I hereby affirm that I am licensed under provisions of Chapter 9 REG. NUMBER S (commencing with Section 7000)of Division 3 of the Business Power Apparatus&Large Appliances DISTRICT NO. PRQCESSED BY and Professions Code,and my license is in full force and effect. �j Size &Type HP, KW, KVA, or KVAR G= �2Lo � - O License Number/ Lic. Class Up to 1 Incl. FINAL U �2. Over 1 to 10 Incl. DATE �r VALIDATION IM Contractor• UNG Date / o Over 10 to 50 Incl. O ElI am exempt under Sec. Over 50 To 100 Inc. LLJ BY '' Over 100 0- B.&P.C. for this reason Services, Swbd., MCC& Ponelboards ® U) Date: Z 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 -.:•.- I hereby affirm that I am exempt from the Contractor's License Sign with One Branch Circuit Law for The following reason (Section 7031.5, Business and Additional Sign Branch Circuits Professions Code): Misc. Conduits&Conductors s )-M`` ❑ I, as owner of the property, will do the work and the structure is not intended or offered for sale(Section 7044, Other (See Complete Fee Schedule)_ ' ;C i €•iL . ; — 75 Business and Professions Code). CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for :l-IOU the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) Q(} (Sec. 3097, Civ. C.). PLAN CHECKING FEEr--s t7_pr Lender's Name {? #I;-3 j jigs y�: 4 PERMIT ISSUING FEE /Gt ,_,i rl t7x, 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 This County to enter upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature ©s e of Permittee Date WORKERS' COMPENSATION DECLARATION 76A663 9DPW 3/a7 APPLICATION FOR ELECTRICAL PERMIT 76A66 I.hereby affirm that I have a ceriificate of consent to self CE-806G insure, dr a tsertificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS or a certified copy Thereof.(Sec. 3800, Lab. C.)71 / Pal icy No. G lJJ d Company FOR APPLICANT TO FILL IN JOB ADDRESS {/0 ❑.Certified copy is/hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE LOCALITY / t ❑Certified copy is filed with the county building inspec- 1 &2-Family, Sq. Ft.l9_S�� $ — $ �L L y7,V Tion department. Multi-family Sq. Ft. NEAREST �/ / CROSS ST. Date "� �� Applicant Z" /T//l/ L G Z- Residential Swimming Pools OWNER OR FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' MAIL COMPENSATION INSURANCE Outlets: Rec Li ht Sw._ j g ADDRESS llo3 - (This section need not be completed if the work involved by First 20 CITY �/ Tel. No. the permit is for one hundred dollars ($100)or less.) Total No. Additional �CK V PLAN CHECK I certify that in the performance of the work for which this APPLICANT permit is issued, I shall not employ any person in any manner Lighting Fixtures First 20 ADDRESS so as to become subject to The Workers'Compensation Laws. Additional Total No. CITY Tel. No. Date Applicant Fixed Appliances Not Over 1 HP NOTICE TO APPLICANT: If, after making this Certificate of PERMIT APPLICATION oLLi JJ Exemption, you should become subject to the Workers' Range— Heater—D.W. — U �/ L' Compensation provisions of the Labor Code, you must forth- Oven — Dryer —W.M.— ADDRESS with comply with such provisions or this permit shall be Top — FAU —W.H. — deemed revoked. Hood — Fan —Other— CITY Tel.- Tel. No. LICENSED CONTRACTORS DECLARATION LICENSE OR Dis — Room Air Cond. — - Class. Q I hereby affirm that I am licensed under provisions of Chapter 9 p REG. NUMBER a S / (commencing with Section 7000)of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO. PROCESSED BY a and Professions Code,and my license is in full force and effect. (� Size&Type HP, KW, KVA, or KVAR CdG�.� e�=-�-� O License Numbery� S 7 Lic, Class a Up to 1 Incl. FINAL > U L6 - , ate D 'fj 5 Over 1 to 10 Incl. DATE G �r / VALIDATION M Contractor Over 10 to 50 Incl. U FINAL ❑ I am exempt under Sec. Over 50 to 100 Inc. BY � �1� �'� W B.&P.C. for this reason Over 100 V IL Date: Services, Swbd., MCC& Panelboards ® Z Z 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 i ;:S" I hereby affirm that I am exempt from the Contractor's License Sign with One Branch Circuit A-4 u t Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits w�= 1! 4 Professions Code): ("OI°__ F-1 1, Conduits&Conductors I, as owner of the property, will do the work and the � r •••�.r•-, Other See Complete Fee Schedule , "tiT4 structure is not intended or offered for sale(Section 7044, ( p )— 3=- 3 T'1= -�•• =�-Y-I' � � - Business and Professions Code). 7 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 PERMIT FEE (Sub-Total) (Sec. 3097, Civ. C.). PLAN CHECKING FEE ; .,-;�_;a}l.I Lender's Name fI •: _ _ _Z. ___. PERMIT ISSUING FEE O Lender's Address I certify that I have read this application and state that the TOTAL FEE fjp ZA 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 IA" (X_11 P u1/ `1i f D ©s Signature of Permittee Das WORKERS' COMN?ENSATION DECLARATION oPwaia7 76A663 APPLICATION FOR ELECTRICAL PERMIT O • 76A663 I t'iereby affirm that I have a certificate of consent to self CE-806G insure, or a or of Workers' Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS or a certified copy thereof.(Sec. 3800, Lab. C.) - �� i/fZ-/'l - Policy No. � , %`4 Company I FOR APPLICANT TO FILL IN JOB Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH rNO FEE ADDRESS a �% ❑Certified copy is filed with the county building inspec- 1 &2-Family, Sq. Ft. 2 2- $ �� $ �� LOCALITY 7 �' tion department. NEAREST Multi-family Sq. Ft. CROSS ST. � i a / cep, Residential Swimming Pools OWNER OR Dao�1 te Applicant d4 �1-,A FIRM NAME (} CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Li g ht Sw.— MAIL o ,3 First 20 9 COMPENSATION INSURANCE ADDRESS f/ 5 (This section need not be completed if the work involved by Total No. Additional CITY 5� � Tel. No. the permit is for one hundred dollars ($100)or less.) PLAN CHECK I certify that in the performance of the work for which this APPLICANT permit is issued, I shall not employ any person in any manner Lighting Fixtures First 20 ADDRESS so as to become subject to the Workers'Compensation Laws. Additional Total No. CITY Tel. No. Date Applicant Fixed Appliances Not Over 1 HP NOTICE TO APPLICANT: If, after making this Certificate of PERMIT /APPLICATION � Z �l Exemption, you should become subject to the Workers' Range- Heater-D.W. D C� s / fZ Compensation provisions of the Labor Code, you must forth- Oven — Dryer —W.M.— ADDRESSJ r �i. �� with comply with such provisions or this permit shall be Top — FAU —W.H. — deemed revoked. Hood — Fan —Other— CITY ZL /a jz Tel. No, LICENSED CONTRACTORS DECLARATION LICENSE OR z Disp. — Room Air Cond. REG. NUMBER irl -S ,� Class.' -/(5I 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. PROCESSED BY d and Professions Code,and my license is in full force and effect. Size &Type HP, KW, KVA, or KVAR0 License Number_ 7 S Lic. Class G Up to 1 Incl FINALDATE �s _ Over 1 to 10 Incl. '2 !�j J� VALIDATION 0 / / c Contractor ! ft/r�(> ��/AU Date FINAL ❑ � � z � � Over 10 to 50 Incl. U I am exempt under Sec. Over 50 to 100 Inc. BY � LU B.&P.C. for this reason Over 100 0- U)Z Date: Services, Swbd., MCC& Ponelboards ® 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 Sign with One Branch Circuit r•; I hereby affirm that I am exempt from the Contractor's License '='=+ a Law for the followingSection 7031.5, Business and Additional Sign Branch Circuits Professions Code): reason ( --'`'��• '`�•-'°_l':, 77 7M11 ❑ 1, as owner of the property, will do the work and the Misc. Conduits&Conductors structure is not intended or offered for sale(Section 7044, Other (See Complete Fee Schedule)— )Ili Business and Professions Code). — _i `" "i} CONSTRUCTION LENDING AGENCY =HE;•``E - I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) (Sec. 3097, Civ. C.). PLAN CHECKING FEE Lender's Name PERMIT ISSUING FEE %3 , Lender's Address / -r 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 this County to enter upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ©s Signature of ermittee Dat