HomeMy Public PortalAbout9240 BLACKLEY ST_Electrical__ 76A663-CE806 9-64
APPLICATION FOR ELECTRICAL P �' T �� .•
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER BUILDING
BUILDING AND SAFETY DIVISION ADDRESS
JOHN A LAMBIE, COUNTY ENGINEER ��77 6,-Y
�I/?
COLEMAN W JENKINS, SUPT OF BUILDING LOCALITY /0L-A" 6, -
NEAREST
FOR APPLICANT TO FILL IN cRoss ST
RECEPT TOTAL NO EACH FEE r
OUTLETS FIRSTd20
$20i OWNER OAwl-
LIGHT MAIL /31/�G,�L�"�
SWITCH OVER
1O ADDRESS �Fu L/'7>✓
OVER
LIGHTING TOTAL FIRST 201 20 CITY ������L-/✓' TELL NrO-� �
FIXTURES _ ADD'L 10 ELECTRICIAN �i�L�Y GL.C -�iQ/C
111 OV R 20 V1
RANGES CLO DRYERS WTR HTRS 100 ADDRESS /01401 (p
GARB DISP STA COOK
CITY TEL NO
DISHWASH AUTO-WASH STATE
SPACE HTRS STA APP (+/z H P MAX 1 50 LICENSE NO 1?34--
MOTORS OVER NOT OVER H P DIST„WCTN GR P Z,/ N PRO SSED BY
O 1 100 d _'7 J
1 3 150INSPECTION RECORD
3 s 200 a
O
B 15 250 V
15 50 300
50 100 500 ,Oyu
SIGNS NO TRANS a
NO LAMPS h
.Z
SERVICE O 600V NOT OVER 200A 1100
SERVICE O 600V OVER 200 A 200
SERVICE OVER 600V 500
MISC
PERMIT ISSUING FEE 200 a
SUPPLEMENTAgY PERMIT ISSUING FEE 1100
TOTAL FEE 3
1HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION APPROVALS DATE 1 Sp CTIOR S SIGNATURE
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CONDUIT
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
:f7 111P 94 4
ELECTRICAL WIRING WIRING
I HEREBY CERTIFY THAT I AM PROPERLY R I TERED AND/OR FIXTURES
LICENSED AS REQUIRED BY LOS ANGELES CO TY AND STATE OF
CALIFORNIA OR THAT LEGAL OWW(OFOPAj.,INTENO TO
RESIDE IN THE ABO D RIBED RE L OYTYPOWER
SIGNATUREUTILITY CO NOTIFIED :71 All
OF PERMITTE
FINAL
9LIDATION
JOSEPH C ROOHAN
MO CASH SUPERVISING ELECTRICAL ENGINEER
L&O 0 6 1 7g, MAR 18 2 D 3.0 0 1;1
WORKER'S COMPENSATION DECLARATION 20 DOI DPW(12 91) APPLICATION FOR ELECTRICAL PERMIT
76A663
I hereby affirm that I have a certificate of consent to self Insure 76A663
ora certlflcate of Worker's Compensation Insurance or a cer d COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV
copy thereof(Sec 3800 atC)
Policy N Company FOR APPLICANT TO FILL INJOB /211
ADDRESS
Certified copy Is hereby furnish New Residential Bldgs &Pools NO EACH FEE LOCALITY —
1 &2-Family,Sq Ft _ $ $
Cefled filed with the r c py Is my buiIdin inspection NEAREST
de rtme Multi-family Sq Ft CROSS ST �j p
Date Applicant ° Residential Swimming Pools MApEgopK �Q PAGE PARCKT�
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets Rec Light_�Sw Q OWNER OR
COMPENSATION INSURANCE First 20 O ° �O FIRM NAME
(This section need not be completed If the work Involved by the Total No Additional ADDRESS
permit Is for one Hundred dollars($100)or less)
I 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 /� �U O PLAN CHECK
become subject to the Workers' Compensation Laws Lighting Fixture 3 First 20 APPLICANT
Total No Additional
- ADDRESS
Date Applicant RESIDENTIAL APPLIANCES NOT OVER 3 HP
NOTICE TO APPLICANT If, after making,this Certificate of CITY Tel No
Exemption,you should become subject to the Workers'Compensation OTHER APPLIANCES NOT OVER 3 HP
IT 9M
provisions of the Labor Code, you must forthwith comply with such APPLICANT
provisions or this permit`shall be deemed revoked Power Apparatus&Large Appliances
LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS/76&
1 hereby affirm that I am licensed under provisions of Chapter 9 Over 3 to 10 Incl
(commencing with Section 7000) of Division 3 of the Business and CITY Tel No
Professions Code, d my license is in full force and effect Over 10 to 50 Incl LICENSE OR a
Over 50 to 100 Incl REG NUMBER Class
?�t Over 100 DISTRICT NO ROCESSED BY Q
mb , "
License NuLlc Cl a c
' Services,Swbd,MCC&Panelboards '�� Cc
Contractor11n�o p� 0 399 Amp Under 600 V FINAL 0
� t'rl DAT �O�-9� U
E
El 400 1000 Amp Under 600V I am exempt under Sec VALIDATION 1 LI
Over 1000 Amp or Over 600 V Fi L a-
6&P C for this reason - BRANCH CIRCUIT FEES BY U)
r Date 15A,or 20A,120V,Lighting or Recept Z
1 To 10 Branch Circuits
Signature 11 To 40 Branch Circuits
El Exemption
Or More Branch Circuits
Exemption for Reg Maint Elect 15A 20A,208V To 277V Lighting Br Circuits
SINGLE FAMILY Temp Power Pole&Appurtenances
HOME OWNER BUILDER DECLARATIONIL
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)
ElI,as owner of the property, will do the work and the structure Misc Conduits&Conductors �- 1 I Er)c-
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) E i r 46 = 20
and Professions Code)
=F!'GI.!! 4c,2f=
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) -
Civ C) Ali)
CHECKING FEE � ^yI I�I-y_f� 1 �1� ��yr_._
Lender's Name IJ� } � yL
PERMIT ISSUING FEE '? y5 r1r, f of
Lender's Address TOTAL FEE / /)
I certify that I have read this application and under penalty of purjury state
I
bove Information is correct I agree to comply with all County
s and State laws regulating Electrical wiring,and hereby authorize
tives of this ounty to enter upon the above mentioned property
i npurpos SEE REVERSE FOR EXPLANATORY LANGUAGE
IA tj 9
OF PERMITTEE 1 4 r DATE