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HomeMy Public PortalAbout4918 GLICKMAN AVE_Electrical__ WOrm -Ohave a TION DECLARATION 76A663 DPW 3/87 APPLIC 'ION FOR ELECTRICAL PERMIT O 76A663 I hereby affirm have a certificate of consent to self CE-806G insure, or a cert...-_,._ of Workers' Compensation Insurance, COUNTY OF ii.v., ANGELES DEPT. OF PUBLIC WORKS or a certified copy thereof (Sec. 3800, Lab. C.) C PolicyNo./A-11401<5Com an STME r t)lvj> FOR APPLICANT TO FILL IN JOB /C) A Company ADDRESS L L�GK/1/I/t/VV& ❑Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE - gio ®Certified copy is filed with the county building inspec- 1 &2-Family, Sq. Ft.,.-A130 $ ❑ $ LOCALITYL&C C I'V - (,'14• tion department. Multi-family Sq. Ft. NEAREST 4 Residential Swimming Pools CROSS ST. }, Date NER OR a )� APPlicant r• �° �`d G• FFIIRM NAME {/�gzd,0/* CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw._ MAIL COMPENSATION INSURANCE ADDRESS f l✓,3 �. <S, rJ /! (This section need not be completed if the work involved by First 20 CITY Tel. No. n` the permit is for one hundred dollars ($100)oress.) Total No. Additional-. PLAN CHECK C 1,�� I certify that in the performance of the w"rk for which this APPLICANT permit is issued, 1 shall not employ anyy erson in any manner Lighting Fixtures First 20 ADDRESS so as to become subject to the Wo I<rs'Compensation Laws. Additional Total No. CITY Tel. No: Date Ap icant Fixed Appliances Not Over 1 HP PERMIT NOTICE TO APPLICA . If, after making this Certificate of APPLICATION /V• U• rhe• Exemption, s ould become subject to the Workers' Range— Heater—D.W. — Compe ion provisions of the Labor Code, you must forth- Oven — Dryer —W.M.— ADDRESS wit amply with such provisions or this permit shall be Top — FAU —W.H. — deemed revoked. Hood — Fan —Other— CITY �L/vfp�� Tel. No�fy)41,6;%36d3 LICENSED CONTRACTORS DECLARATION LICENSE OR /- /, 7 Disp. — Room Air Cond. — REG. NUMBER J 107"7/ Class.G-1v 1 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 and Professions Code,and my license is in full force and effect. �G�v �/ Size&Type HP, KW, KVA, or KVAR /�� O License Number c�l®`T7 7 Li c. Class -`l Up to 1 Incl. FINAL U Over 1 to 10 Incl. DATE r VALIDATION CC Contractor Cf6/�N' C4L''Qi✓��Date Z✓ O Over 10 to 50 Incl. FINAL ~ ❑ I am exempt under Sec. Over 50 to 100 Inc. BY U W Over 100 B.&P.C. for this reason W Services, Swbd., MCC& Panelboards Date: 0-200 Amp. Under 600 V Signature 201 - 1000 Amp. Under 600 V El Over 1000 Amp. or Over 600 V Exemption for Reg. Maint. Elect. ,. ' - SINGLE FAMILY Temp. Power Pole&Ap(0 enances HOME OWNER-BUILDER DECe,/RAT11ONN I hereby affirm that I am ee Contractor's License Sign with One Branch Circuit xempt fro th Law for the following reason (S tion 7031.5, Business and Additional Sign Branch Circuits Professions Code): Ell, as owner of the operty, will do the work and the Misc. Conduits&Conductors .. structure is not int nded or offered for sale(Section 7044, Other (See Complete Fee Schedule)_ Business and P fessions Code). STRUCTION LENDING AGENCY I hereby a irm that there is a construction lending agency for the per rmance of the work for which this permit is issued PERMIT FEE (Sub-Total) ` (j (Sec. 97, Civ. C.). PLAN CHECKING FEE -; rider's Name i1 `"•' """"' _. "• 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 this County to enter upon the abo�re- .entioned r e?ty fo�in ection pur oses. SEE REVERSE FOR EXPLANATORY LANGUAGE ©s gna1.e of ermittee Date