HomeMy Public PortalAbout4950 GLICKMAN AVE_Electrical__ WORKE - a certificate
DECLARATION 76A669 DPW 9189 APPLIC ION FOR ELECTRICAL PERMIT
76A663
I hereby affirm that � a certificate of consent to self insure, I
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.38000 Lab. C.) T
Policy No. 0�/ Company :/�Ti<�• 45 FO-11-0 FOR APPLICANT TO FILL IN 'OB
ADDRESS
Certified copy is hereby furnished. New Residential Bldgs.&Pools EACH NO. FEE l `
C LOCALITY y�
Certified copy is filed with the county building inspection 1 &2-Family,Sq.Ft. NEAREST
department. Multi-family Sq.Ft. CROSS ST.
Date Applicant �(J Residential Swimming Pools ASSESSOR
MAP BOOK PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec. Light Sw. OWNER OR NAME
COMPENSATION INSURANCE FIRMa
(This section need not be completed if the work involved by the First 20 MAILTotal No. Additional ADDRESS
permit is for one hundred dollars($100)or less.)
I certify that in the performance of the work which this permit CITY , I Tel.No. ��
is issued, I shall not employ any pers n any manner so as to PLAN CHECK
become subject to the Workers' Co ensation Laws. Lighting Fixtures First 20 APPLICANT
Total No. Additional
ADDRESS
Date Applicant 15 OR 20A,120V BRANCH CIRCUITS
NOTICE TO LICANT: If, after making this Certificate of CITY Tei.No.
Exempt! , ou should become subject to the Workers' Compensation 1 TO 10 INCLUSIVE EACH /
provt5rons of the Labor Code, you must forthwith comply with such 11 TO 40 INCLUSIVE EACH PERAPPLICANT
IT
provisions or this permit shall be deemed revoked. 41 OR MORE BRANCH CIRCUITS EACH
LICENSED CONTRACTORS DECLARATION ADDRESS 7JIZ6r "r6d
1 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 .::t Tel.N /ir �P�
Professions Code, and my license is in full force and effect. RESIDENTIAL APPLIANCES UP TO 3HP LICENSE OR w Y*d 3
Power Apparatus&Large Appliances REG.NUMBER '��77 Class.
o
1 4 Lic.Class C Size&Type HP,KW,KVA,or KVAR DISTRICT NO. p P CES D BY
License Number ��
Up to 3 Incl. � W
Over 3 to 10 Incl. FINAL 13-
Contractor
Contractor Date DATE fly
❑ Over 10 to 50 Incl. /O`2,3^ L Z
I am exempt under Sec. Over 50 to 100 Incl. 1 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.
I
SINGLE FAMILY Temp.Power Pole&Appurtenances
HOME OWNER-BUILDER DEC' AR ON
I hereby affirm that I am exempt from the C rector's License Law Sign with One Branch Circuit
for the following reason (Section 7031. usiness and Professions Additional Sign Branch Circuits
Code):
❑ I, as owner of the pro rty,will do the work and the structure Misc.Conduits&Conductors
( is not intended o ffered for sale (Section 7044, Business Other(See Complete Fee Schedule) , ;•.t;-•;.,, -
and ProfessI Code).
i f.l
NSTRUCTION LENDING AGENCY --
I hereby affi that there is a construction lending agency for the
performan of the work for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total) _
Civ. C.
PLAN CHECKING FEE
Le der's Name
PERMIT ISSUING FEE /f
Lender's Address
I certify that I have read this application and state that the above TOTAL FEE /G'
information is correct. 1 agree to comply with all County ordinances /
and State laws regulating Electrical wiring, and hereby authorize
representative of this Co {Ity to r upon the above-mentioned
grope pec' n dr SEE REVERSE FOR EXPLANATORY LANGUAGE
.".NAT" OFAPPLICANT RAGENT DATE