HomeMy Public PortalAbout5331 GLICKMAN AVE_Electrical__ �I
WORKERS' COMPENSATION DECLARATION 76A66310/81 APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self CE-806G
inCE-806sure, or a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified copy thereof (Sec. 3800, Lab. C.)
Policy No. Company FOR APPLICANT TO FILL'IN JOBryA/I ' c
F-1Certifiedcopy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADDRESS A4 i7 ,/V>lr_
Certified copy is filed with the county building inspec- 1 &2-Family, Sq. Ft. $ — $ LOCALITY
tion department. Multi-family Sq. Ft. — 'NEAREST q�
CROSS ST.
Residential Swimming Pools 45Date A �P e-
licanf OWNER O ,(meq f 1 J
FP R
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw._ MAIL
COMPENSATION INSURANCE ADDRESS ' . ZS N
(This t bom completed if the work involved b First —
( s section neenoe cp Y Total No. Additional CITY - L � Tel. No.C.ff.ty `j'7'7
the permit is for one hundred dollars($100)or less.)
that in the performance of the work for which this PLAN CHECK
I certify P APPLICANT
permit is issued, I shall not employ any person in any manner
so as to become subject to.the Workers'Comp ns�afifn'laws. Lighting Fixtures First 20 ADDRESS
Total No. Additional CITY Tel. No.
Date � Applicant -- Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, after making this Certificate of I APPLICANT 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
with comply with such provisions or this permit shall be Top FAU —W.H. —
deemed revoked. CITY Tel. No.
LICENSED CONTRACTORS DECLARATION Hood _ Fan _Other—
LICENSE o - a
I hereby affirm that I am licensed under provisions.of Chapter 9 Disp. Room Air Cond. REG. NUMM BER ,_,73 / �C">-/7� Class. C- o ,
(commencing with Section,7000) of Division 3 of the Business DISTRICT NO. PROCESSED BY
and Professions Code,and my license is in full force and effect. Power Apparatus& Large Appliances _ / _ CL
/ Size &Type HP, KW, KVA, or KVAR' OC/ O
License Number �� ®'Lic. Class �`(� Up to 1 Incl. FINAL -.
��� �Z 3, Over 1 to 10 Incl. DATE t/�•'j Z - VALIDATION IX
Contractor Date Over 10 to 50 Incl. �//
FINAL U
a
I am exempt under Sec. Over 50 to 100 Inc. BY A+
B.&P.C. for this reason Over 100 Z
Date:
Services, Swbd., MCC&Panelboards ► �' �� �
0 -200 Amp. Under 600 V 900
Signature 201 - 1000 Amp. Under 600 V r"�¢
❑ 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 Contractor's LicenseAdditional Sign Branch Circuits %7 20,2 A
Law for the following reason (Section 7031.5, Business and
Professions Code): ! ° 0 0 0 0 2
E] I, as owner of the property, will do the work and the Misc. Conduits&Conductors • ' r
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)— , .2 ° ° 25,
5 Q
7044, Business and Professions Code).
'°:°'° 2550
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for 0,2.8—8 2
the performance of the work for which this permit is issued PERMIT FEE (Sub-Total)
(Sec. 3097, Civ. C.).
PLAN CHECKING FEE Q
Lender's Name
PERMIT ISSUING FEEt
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 authorizer presentatives of this County to enter upon
thea e-horfz e r r rty for inspection purp see.
SEE REVERSE FOR EXPLANATORY LANGUAGE
ignature of Permittee G Date /