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HomeMy Public PortalAbout5006 GLICKMAN AVE_Electrical__ WORK I have cerci DECLARATION 20-0019 DPW 3/87 APPLI( TION FOR ELECTRICAL PERMIT O 76A663 I hereby affirm I have a certificate of consent to self CE-806G insure, or a cer...._....; of Workers' Compensation Insurance, COUNTY OE r v.� ANGELES DEPT. OF PUBLIC WORKS or a certified copy thereof (Sec. 3800, Lab. C.) Policy No.07 a Company E _/7/f�/ �. R+' FOR APPLICANT TO FILL IN JOB ❑Certified cop 'is ereby furnished. New Residential Bldgs. & Pools EACH rNO FEE ADDRESS ��// $` C $ LOCALITv�f Certified copy is filed with the county building inspec- 1 &2-Family, Sq.vv��tion department. Multi-family Sq. Ft. NEAREST CROSS ST. Date Applicant ' Residential Swimming Pools OWNER OR FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw._ MAIL COMPENSATION INSURANCE ADDRESS S fi(112[1L� ` N First 20 (This section need not be completed if the work involved by Total No. Additional CITY zb�1r^' Tel. NoSi the permit is for one hundred dollars ($100)or le .) PLAN CHECK I certify that in the performance of The wo or which this APPLICANT permit is issued, I shall not employ an son m any manner Lighting Fixtures First 20 ADDRESS so as to become subject to the W rs'Compensation Laws. Additional Total No. CITY Tel. No. Date plicant Fixed Appliances Not Over 1 HP PERMIT f NOTICE TO APPL T: If, after making this Certificate of APPLICATION 1, / C Exemption, should become subject to the Workers' Range— Heater—D.W. — Compens on provisions of the Labor Code, you must forth- Oven — Dryer —W.M.— ADDRESSaze with mply with such provisions or this permit shall be Top — FAU —W.H. — de ed revoked. Hood — Fan —Other— CITY S Tel. No. � LICENSED CONTRACTORS DECLARATION LICENSE OR Disp. — Room Air Cond. Class. I hereby affirm that I am licensed under provisions of Chapter 9 REG. NUMBER (commencing with Section 7000)of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO. PM ED BY and Professions Code,and my license is in full force and effect. Size &Type HP, KW, KVA, or KVAR Li�f�� 0 License Number ld Lic. Classes '' Up to 1 Incl. FINAL U Over 1 to 10 Incl. DATE /y VALIDATION IM Contractor {��� � /� Date 2� 12--t ( � O ❑ Over 10 to 50 Incl. U FINAL I am exempt under Sec. Over 50 to 100 Inc. BY W B.&P.C. for this reason Over 100 a- Services, Swbd., MCC& Panelboards ® Cl) Date: 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 DECLARATIO I hereby affirm that I am exempt from the C ractor's License Sign with One Branch Circuit Law for the following reason (Section 1.5, Business and Additional Sign Branch Circuits ' Professions Code): ❑ I, as owner of the prop y, will do-the work and the Misc. Conduits&Conductors structure is not intend or offered for sale(Section 7044, Other (See Complete Fee Schedule)_ Business and Prof ions Code). CONS UCTION LENDING AGENCY I hereby affirm at there is a construction lending agency for the perform ce of the work for which this permit is issued PERMIT FEE (Sub-Total) (Sec. 3097 Civ. C.). PLAN CHECKING FEE Len is Name – PERMIT ISSUING FEE "" J.- "- T. Lender's Address A7 ,'55- 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 authori a repres f this County to enter upon the ab nt• a peitoinspection p�urp ses. SEE REVERSE FOR EXPLANATORY LANGUAGE ©s Sign ,`u,-661 Permit a Date