HomeMy Public PortalAbout6322 AGNES AVE_Electrical__ TEMPLE CqTl"p
76A663-CE806 8-62
APPLICATION FOR ELECTRICAL PERMIT
/ _,:� COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER BUILDING
BUILDING AND SAFETY DIVISION ADDRESS
JOHN A LAMBIE COUNTY ENGINEEt
/!
WILLIAM A JENSEN SUP T OF BUILDING LOCALITY ��fiG� G(7'Y
NEAREST
FOR APPLICANT TO FILL IN CROSS sT
RECEPT TOTAL NO EACHOUTLETS FIRST 20 $20 OWNER
LIGHT MAIL
ADDL 10 ADDRESS
SWITCH OVER 20
TOTAL CITY
.� TEL NO
LIGHTING FIRST 20 20
FIXTURES I ADDL
I
OVER 20 10 ELECTRICIAN
RANGES CLO DRYERS WTR HTRS 1 OO ADDRESS
GARB DISP STA COOK
CITY TEL NO
DISHWASH AUTO WASH STATE
SPACE HTRS STA APP (+/y H P MAX ) 50 LICENSE NO
MOTORS OVER NOT OVER H P DISTRICT N G 7
P RQCW ED
O 1 1 00 �
1 a 150 INSPECTION R CORD
s a 200 A;ej
B 15 250
15 50 300 1,,71 0
50 100 500 �> G L)
No TRANS
SIGNS NO LAMPS �`\ f ����a�,�j^ / � Q � O
SERVICE O 600V NOT OVER 200A 100
SERVICE O 600V OVER 200 A 200
Z
SERVICE OVER 600V 500
MISC -
PERMIT ISSUING FEE 200
SUPPLEMENTARY PERMIT ISSUING FEE 1100,
TOTAL FEE
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION APPROVALS DATE INSPECTORS SIGNATURE
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CONDUIT / �.+L✓
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
ELECTRICAL WIRING WIRING ,6 ,I;V/
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR 1 r
LICENSED AS R UIRED BY LOS ANGELES COUNTY AND STAT OF FIXTURES
CALIFORNIA OR T 1 AM THE LEGAL OWNER F THE VE /'
DESCRIBED REBID AL PROPERTY POWER /
SIGNATURE' UTILITY CO NOTIFIED
OF PERMITTEE
FINAL
VALIDATION—) A4 4T Hb R C VEIT
CK MO CASH SUPEAVISING ELECTRICAL ENGINEER
WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12-91) APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self insure, 76A663
or a certificate of Worker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT:OF PUBLIC WORKS BUILDING AND SAFETY DIV.
CLVy thereof(Sec.3800 Lab. C.)
Po
licy No. Company FOR APPLICANT TO FILL IN JOB
ADDRESS
copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE /�
g _ $ $ LOCALITY �ii1
Certified co Is filed with the count building inspection 1&2-Family,Sq.Ft.
PY Y 9 P — NEAREST j
department. Multi-family Sq.Ft. CROSS ST. .[�!
Date Applicant Residential Swimming Pools ASSESSOR
MAP PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:RBC. Light Svv.1 OWNER OR
"2 ZF FIRM NAME
First 20
COMPENSATION INSURANCE MAIL
(This section need not be completed if the work involved by the Total No. Additional ADDRESS S
permit is for one hundred dollars($100)or less.)
1 certify that in•the performance of the work for which this permit CITY Tel.No.
is issued, I shall not employ any person in any manner so as to PLAN CHECK
become subject to the Workers' Compensation Laws. Lighting Fixture First 20 APPLICANT
Total No. Additional /
ADDRESS
Date Applicant — APPLIANCES NOT OVER H
L APPLP. .�v ��
NOTICE TO APPLICANT: If, after making this Certificate of CITY —7:; Tel.No.
Exemption,you should become subject to the Workers'Compensation OTHER APPLIANCES NOT OVER 3 HP.
provisions of the Labor Code, you must forthwith comply with Such PERMIT
provisions or this permit shall be deemed revoked. Power Apparatus&Large Appliances APPLICANT
LICENSED CONTRACTORS DECLARATIONSize&Ty pg HP,KW,KVQ,or KVAR ADDRESS
1 hereby affirm that l am licensed under provisions of Chapter 9 �/61y�/r/�/to 10 Incl.
(commencing with Section 7000) of Division 3 of the Business and CITY Tel.No.
Professions Code,and my license is in full force and effect. Over 10 to 50 Incl. LICENSE OR :'=L•t_•i r� �"
• Over 50 to 100 Incl. REG.NUMBER Z CI'ass. , d
I, Over 100 _r_a'.
License Number ll Lic.Class DISTRICT NO. ry/ P ED BY
n Service ,�yb � P,WTelboards GLKi �� Q
Contractor ` L Date V' Amp.Under 600 V DATE sL __ .mss
400-1000 Amp. Under 600 V /-qf
ElydLIDATION
I am exempt under Sec. Over 1000 Amp.or Over 600 V FINAL �+
B.&P.C.for this rea n _ BY sf<I �,jlCn
BRANCH CIRCUIT FEES
e: 15A,or 20 120V,Lighting or Recept. Q _
1 To 10 Branch Circuits
Signature f ii
11 To 40 Branch Circuits »
T i
El Exemption
Or More Branch Circuits y.�L
Exemption for Reg.Maint.Elect. 15A,20A,208V To 277V Lighting Br.Circuits I"t"?'
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 License Law
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits
Code):
❑ I,as owner of the property,will do the work and the structure Misc.Conduits&Conductors
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) '
and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the
performance of the work for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total) /r
Civ. C.)
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE
Lender's Address
I certify that I have read this application and under penalty of purjury state TOTAL FEE
that the above information is correct. I agree to comply with all County
ordinances State laws regul ' g Electrical wiring,and hereby authorize
representative of this my to nter upon the above-mentioned property
for inspectio rp e SEE REVERSE FOR EXPLANATORY LANGUAGE
3�-ter,. qs
SIGNATURE OF PERMITTEE DATE