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Home My Public Portal About5221 GLICKMAN AVE_Electrical__ WORKERS'COMPENSATIONDECLARATION 76A663 _0q CE-806G (2-80) APPLICATION FOR ELECTRICAL PERMIT ' CE-806 I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY insure, or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Seca 3800,Lab.C.) Policy No: Company `�o�; ICY FOR APPLICANT TO FILL IN JOB EACH NO. FEE El Certified �?��/ a New Residential Bldgs.&Pools Certified copy is hereby furnished. 1 &2-Family,Sq. Ft. $ — Is I LOCALITY Multi-family Sq. Ft. NEAREST Certified copy is filed with the county building inspection CROSS ST department. Residential Swimming Pools OWNER OR ��gp- /'® FIRM NAME ( r Date Applicant Outlets: Rec.-Light Sw. 1/j/ i MAID S' First 20 CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. Additional CITY Tel No-243 . COMPENSATION INSURANCE d b"'' PLAN CHECK APPLICANT (This section need not be completed if the work involved U by the permit is for one hundred dollars Fixtures First 20 s ($100) or less.) ADDRESS Additional cc Total No. I certify that in the performance of the work for which this CITY Tel No. Fixed Appliances Not Over 1 HP permit is issued, I shall not employ any person in any manner PERMIT 0 so as to become subject to the Workers' Compensation Laws. lJJ Range_ Heater_D.W. APPLICANT QCL J Oven Dryer_W.M._ ADDRESS- % U) /�•z Date Applicant Top — FAU _W.H.,_ ®. Hood _ Fan _Other_ CITY T el No.7j� `7.S NOTICE TO APPLICANT: If, after making this Certificate of Disp. Room Air Cond.— LICENSE OR Exemption, you should become subject to the Workers' REG.NUMBER Class Compensation provisions of the Labor Code, you must forth- Power Apparatus& Large Appliances DISTRICT NO. PROCESSED BY with comply with such provisions or this permit shall be deemed revoked. Size&Type HP,KW, KVA,or KVAR `. _ " Up to 1 Incl. ' Over 1 to 10 Incl. FINAL LICENSED CONTRACTORS DECLARATION DATE ] VALIDATION Over 10 to 50 Incl. I hereby affirm that I am licensed under provisions of Chapter Over 50.to 100 Inc. FINAL 9 (commencing with Section 7000) of Division 3 of the Busi- Over 100 B /l ness and Professions.Code, and my license is in full force and - effect. Services 0-200 Amp. Under 600 V License Number Lic. Class 201-1000 Amp.Under 600 V Contractor Date Over 1000 Amp.or Over 600 V HOME OWNER-BUILDER DECLARATION Temp. Power Pole&Appurtenances I hereby affirm that I am exempt from the Contractor's Sign with One Branch Circuit License Law for the following reason (Section 7031.5, Busi- Additional Sign Branch Circuits ness and Professions Code): J'6 2,7 A Misc.Conduits&Conductors El I, as owner of the property, will do the work and the { o 0 0 0 0 2 Other (See Complete Fee Schedule)— structure is not intended or offered for sale (Section 7044,Business and Professions Code). 2 oto 1 0.90 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency 0 0 c Q 9 0 El- for the performance of the work for which this permit is PERMIT FEE (Sub-Total) issued(Sec. 3097,Civ.C.). Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee) Lender's Address PERMIT ISSUING FEE j I certify that I have read this application and state that the TOTAL FEE Iraabove information is correct.I agree to comply with all County ordinances and State laws regulating Electrical wiring, and hereby ayihor-ize-representatives-o is County to enter upon !S ` he-abveK��menti ne c i urposes SEE'REVERSE FOR EXPLANATORY LANGUAGE ' nature o er ' tee Dat 76A663-CE806 5.62 APPLICATION FOR ELECTRICAL PERMIT COUNTY OF LOS ANGELES A DEPARTMENT OF COUNTY ENGINEER) /',/„ BUILDING BUILDING AND SAFETY DIVISION ADDRESS JOHN A. LAMBIE, COUNTY ENGINEER ��,��r WILLIAM A. JENSEN, SUPT OF BUILDING LOCALITY NEAREST FOR APPLICANT TO FILL IN CROSS ST. RECEPT. TOTAL NO. EACH FEE OUTLETFIRsr 20 $20 $ OWNER LIGHT ,.i MAIL ADD'LD ADDRESS SWITCH. � OVER 20 10 TOTAL CITY TEL. N LIGHTING FIRST 201/ .20 FIXTURES /� ADD'L 10 ELECTRI AN OVER 20 J RANGES CLO.DRYERS WTR.HTRS. 1.001 ADDRESS GARB.DISP. STA.COOK i NO. DISH WASH. AUTO.-WASH. CITY TEL.STATE SPACE HTRS. STA.APP.I'/z H.P.MAX. 6 ,50 LICENSE NO. MOTORS: OVER NOT OVER H.P. DISTRICT NO. GRO ZO E PRQrE SED a O 1 1.00 `) 1 3 1,50 INSPECTION RECORD 3 8 2.00 8 15 2.50 0- 15 15 50 3.00 0 50 100 5.00 O SIGNS: NO.TRANS H NO.LAMPS W / a SERVICE 0.600V-Nor OVER 200A 1.00 � Z SERVICE 0.60OV-OVER 200 A. 2.00 SERVICE OVER 600V 5.00 MISC. PERMIT ISSUING FEE 2.00 '� SUPPLEMENTARY PERMIT ISSUING FEE 1.00 TOTAL FEE $ I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION APPROVALS DATE INSPECTOR'S SIGNATURE AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CONDUIT WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ELECTRICAL WIRING. WIRING I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR 7 r' LICENSED AS REQUIRED BX LOS ANGEL CO NTY AND TATE OF FIXTURES CALIFORNIA OR THAT 1 M T E LEG L O ER F E ABOVE DESCRIBED RESIDENT[ R RTY. POWER SIGNATURE UTILITY CO.NOTIFIED OF PERMITTEE FINAL ALIDATION ARTHUR C. VEIT CK MO CASH SUPERVISING ELECTRICAL ENGINEER LAI-09 0 03'0 JAN 2 2 D 1 6.40- ,