HomeMy Public PortalAbout4958 GLICKMAN AVE_Electrical__ WORKF ) a certificate
DECLARATION 76A669 DPW 9/89 /�PPLIC ®N FOR ELECTRICAL PERMIT
76A663 !1 L
I hereby affirm that � 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.) �J�^
Policy No. O Company::: 7/7 FV/I� FOR APPLICANT TO FILL IN JOB
ADDRESS 14 <iG
X7,7/ Certified copy is hereby furnished. New Residential Bldgs.&Pools EACH NO. FEE LOCALITY —�-v
l� Certified co is filed with the count building inspection 1 &2-Family,Sq.Ft. C $' — $
PY Y 9 P _ NEAREST
department. Multi-family Sq.Ft. CROSS ST.
Date Applicant '�U -�,v G• Residential Swimming Pools MAP SSOK PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec. Light Sw. OWNER OR7�X�W
COMPENSATION INSURANCE FIRM NAME !
( p y First 20 ADDRESS SSi�/�Cr
This section need not be completed if the work involved b the MAIL
Total No. Additional ��
permit is for one hundred dollars($100)or less.)
I certify that in the performance of the wort hich this permit CITY S.�f7 7e1.No.�Qf��GB��
is issue>subject
employ an n in any manner so as to PLAN CHECK v
become Wo Compensation Laws. Lighting Fixtures First 20 APPLICANT
Total No. AdditionalADDRESS
Date Applicant 15 OR 20A,120V BRANCH CIRCUITS
NOTICE TO APPLICANT: If, after making this Certificate of CITY Tel.No.
Exemption,you should become subject to the Workers'Compensation 1 TO 10 INCLUSIVE EACH
provisions of the Labor Code, you must forthwith comply with such 11 TO 40 INCLUSIVE EACH PERMIT
P Y P Y APPLICANT
provisions or this permit shall be deemed revoked. 41 OR MORE BRANCH CIRCUITS EACH n
LICENSED CONTRACTORS DECLARATION ADDRESS Z U v
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 5- �L ��yl'� Tel.No�� �Q/ -
Professions Code, and my license is in full force and effect. RESIDENTIAL APPLIANCES UP TO 3HP LICENSE OR /
/ Power Apparatus&Large Appliances REG.NUMBER �! Class. C l0
License Number / Lic.Class C~` Size&Type HP,KW,KVA,or KVAR DISTRICT NO. p PROC SSED BY
Up to 3 Incl. fJ p W
Contractor �' `�"SAN" Date (` �( / Over 3 to 10 Incl. CL
DATE
❑ Over 10 to 50 Incl 7 W
I am exempt under Sec. Over 50 to 100 Incl. Z Z(�q % 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 DECLARATIO Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contra or's License Law
for the following reason (Section 7031.5, Bus' ess and Professions Additional Sign Branch Circuits -
Code):
ElI,as owner of the property, i do the work and the structure Misc.Conduits&Conductors
is not intended or offer for sale (Section 7044, Business Other(See Complete Fee Schedule)
and Professions Cod
CON UCTION LENDING AGENCY
I hereby affirm th there is a construction lending agency for the
performance o he work for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total)
Civ.C.)
PLAN CHECKING FEE
Lend s Name
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 County to enter upon the above-mentioned
propert r ;�flonppo SEEREVERSE FOR EXPLANATORY LANGUAGE
TIRE nSIGNATURE PP CENT DATE