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HomeMy Public PortalAbout5014 GLICKMAN AVE_Electrical__ WORK I have cerci DECLARATION 720-0019 6A663DPW3/87 APPLI( PION FOR ELECTRICAL PERMIT O I hereby affirm I have a certificate of consent to self CE 806G insure, or a cer...._... of Workers' Compensation Insurance, COUNTY OV LvZ' ANGELES DEPT. OF PUBLIC WORKS or a certified copy thereof (Sec. 3800, Lab..CA j Policy No a2- 2 Company G FOR APPLICANT TO FILL IN JOB ❑Certified copyi hereby furnished" New Residential Bldgs. & Pools EACH NO. FEE ADDRESS 7 ertified copy is filed with the county building inspec- 1 &2-Family, Sq. Ft.�%�-% LOCALITY � tion depar me 1. Multi-family Sq. Ft. NEAREST �� r'V Avc Residential Swimming Pools CROSS ST. Date Applicant OWNER ORM FIRM NAME ��✓ CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw._ MAIL `' COMPENSATION INSURANCE ADDRESS 5, 5eiftC�alk_l�' /7 First 20 ` (This section need not be completed if the work involved by Total No.— Additional CITY X7,2 Tel. No. the permit is for one hundred dollars ($100)or s.) PLAN CHECK I certify that in the performance of the for which this APPLICANT permit is issued, I shall not employ an ersan in any manner so as to become subject t�c. thers'Compensation Laws. Lighting Fixtures First 20 ADDRESS Additional Total No. CITY Tel. No. Date �� Fixed Appliances Not Over 1 HP PERMIT NOTICE TO AP �C,HNT: If, after making this Certificate of APPLICATION Exemption -u should become subject to the Workers' Range— Heater—D.W. — Compe -tion provisions of the Labor Code, you must forth- Oven — Dryer —W.M.— ADDRESS it comply with such provisions or this permit shall be Top — FAU —W.H. — med revoked. Hood — Fan —Other— CITY _571 67L AIJAIM Tel. Nocl� LICENSED CONTRACTORS DECLARATION LICENSE OR //,, I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. REG. NUMBER ���4Y Class. rU (commencing with Section 7000)of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO. PSED BY >_ and Professions Code,and my license is in full force and effect. / 0- Size &Type HP, KW, KVA, or KVAR �. �✓ax�it� 0 License Number"Z/ 1-7�/��Lic. Class4/ Up to 1 Incl. FINAL U Contractorlcf� G/1� �%�"`D �/ Zi Over 1 to l0 Incl. DATE `R VALIDATION 0 ate Over 10 to 50 Incl. ElFINAL I am exempt under Sec. Over 50 to 100 Inc. BY U B.&P.C. for this reason Over 100 a_ Services, Swbd., MCC& Panelboards ® Z 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 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 Business and Additional Sign Branch Circuits Professions Code): -= --• - - ❑ I, as owner of the prop , 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 ons Code). CON UCTION LENDING AGENCY - I hereby affir at there is a construction lending agency for the perfor nce of the work for which this permit is issued PERMIT FEE (Sub-Total) (Sec. 30 , Civ. C.). PLAN CHECKING FEE Le er's Name - ••• - --- .. _. .._ PERMIT ISSUING FEE Lender's Address ---- :•'. 1 certify that I have read this application and state that the TOTAL FEE ''G above information is correct. I agree to comply with all.County ordinances and State laws regulating Electrical wiring, and hereby autho ' e repres lqtives of this County to enter upon the ab - e�nn �pe, �r nspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ©s Sig Lure of Per tee Date