HomeMy Public PortalAbout5000 GLICKMAN AVE_Electrical__ WORKS Ohave a TION DECLARATION 766663 DPW 3/87 APPLIC BION FOR ELECTRICAL PERMIT O
I hereby affirm have a certificate of consent to self CE-806Ginsure, or a cert...__._ of Workers' Compensation Insurance, COUNTY OF ova ANGELES DEPT. OF PUBLIC WORKS
or a certified copy thereof (Sec. 3800, Lab. Cl
Policy No. O ' Company � � FOR APPLICANT TO FILL IN JOB ��r
❑Certifiedied copy furnished. New Residential Bldgs. & Pools / EACH PNO, FEE ADDRESS
ertified copy is filed with the county building inspec- 1 &2-Family, Sq. Ft. f�� $• $ LOCALITY —, /(
tion department. Multi-family Sq. Ft. NEAREST
/ Residential Swimming Pools CROSS ST.
Date Applicant A��l���L C OWNER
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw.— MAIL Y>I
COMPENSATION INSURANCE ADDRESS O �, SizaL %fit
First 20
(This section need not be completed if the work involved by Total No. Additional CITY ,tet I� 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
so as to become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS
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
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 T L Xva� .4—'M16,
with comply with such provisions or this permit shall be Top — FAU —W.H. —
deemed revoked. CITY �C �[//!� .,. � jd-
Hood Fan —Other— Tel. No
LICENSED CONTRACTORS DECLARATION LICENSE OR f9 Class.), '7
Disp. — Room Air Cond. — REG. NUMBER S`1 / C__/0I 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. PR CESSED BY >_
and Professions Code,and my license is in full force and effect. �� ��_ CL
Size&Type HP, KW, KVA, or KVAR (� ' O
License Number 477 Lic. Class y Up to 1 Incl. FINAL U
Contractor /'� G1+�/✓ Date L- Over 1 to 10 Incl. DATE y_ ,L� VALIDATION 0
❑ Over 10 to 50 Incl. GI—
FINAL U
I am exempt under Sec. Over 50 to 100 Inc. BY c W
Over 100 d
G'
B.&P.C. for this reason OveCf)Services, Swbd., MCC& Panelboards z
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 DECLARATION Sign with One Branch Circuit _
I hereby affirm that I am exempt from the Contr or's License
Law for the following reason (Section 70 .5, Business and Additional Sign Branch Circuits
,.
Professions Code):
❑ I, as owner of the pro Misc. Conduits&Conductors
p y, will do the work and the Other See Complete Fee Schedule
structure is not inten or offered for sale(Section 7044, ( P )—
Business and Pr ssions Code).
STRUCTION LENDING AGENCY _
[hereby irm that there is a construction lending agency for
the p ormance of the work for which this permit is issued PERMIT FEE (Sub-Total)
(S . 3097, Civ. C.).
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE p�2 Z/ � _-•._.. __
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 represents ' of is County to enter upon
the abo on pr
.er� inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Os
Signal cof ermi a Date