HomeMy Public PortalAbout9435 BLACKLEY ST_Electrical__ 7GA663 CE806 10-62 APPLICATION FOR ELECTRICAL PERMIT
1
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER BUILDING
BUILDING AND SAFETY DIVISION ADDRESS Y
JOHN A LAMBIE, COUNTY ENGINEER
WILLIAM A JENSEN, SUP T OF BUILDING LOCALITY _
NEAREST
FOR APPLICANT TO FILL IN CROSS ST
RECEPT TOTAL 10 NO EACH FEE
OUTLETS FIRST 20 $20 $ OWNER
LIGHT 4 MAIL
SWITCH
OVER LO 10 ADDRESS
TOTAL ` CITY TEL NO
LIGHTING � FIRST 20 ! 20
FIXTURES ADD L -1O ELECTRICI
OVER 20
RANGES CLO DRYERS WTR HTRS 100 ADDRESS '4/V
ARB DISP STA COOK O�/
CITY TEL NO O
DISH WASH AUTO-WASE/ STATE r �J }'
SPACE HTRS STA APP ('h H P MAX ) 3 50 LICENSE NO/61 / / J /
MOTORS OVER NOT OVER H P DISTP (`S ILIO R P E D
O 1 loo
��� o Qi
1 3 15 INSP CTION RECORD
3 8 200
CL
8 15
250 0
15 50 300 pt
50 100 500 O
SIGNS NO TRANS G.
NO LAMPS vj
z_
SERVICE 0-600V NOT OVER 200A 100
SERVICE O 600V OVER 200 A - 200
SERVICE OVER 600V 500
MISC
PERMIT ISSUING FEE 200
SUPPLEMENTARY PERMIT ISSUING FEE 100
TOTAL FEE $
1 HEREBY ACKNOWLEDGE THAT I 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 ✓ ��
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR
LICENSED A9 R RED BY LOS ANGELE COUNTY AND STATE OF FIXTURES
CALIFORNIA O T AT I AM THE LEGA OWNER OF THE ABOVE A
DESCRIBED REST TI PROPERT POWER
SIGNATURE UTILITY CO NOTIFIED c��`ri7T lfr� /
OF PERMITT
FINAL rf7, P
( LIDATION A HUR C' VEIT
CK' MO CASH SUPERVISING ELECTRICAL ENGINEER
CK' MO CASH
LACO5 3 0 1G FEB 5 2 D 1 ,3.6 Cr N
WbRKERS COMPENSATION DECLARATION CE 806G (2 80) APPLICATION, FOR ELECTRICAL PERMIT
I herebyaffirm that I have a certificate of consent to self COUNTY OF LOS AN LES DING AND SAFETY � ,
insure, ora certificate of Workers'Compensation Insurance,or
a certified"Copy ihereof(Sec 3800, Lab C)
FOR APPLICANT TO FILL IN ,JOB pp
Policy No Company EACH NO FEE ADDRESS p�
New Residential Bidgs &Pools
Certified copy is hereby furnished 1 &2-Family,Sq Ft $ — $ LOCALIT
Multi-family Sq Ft — NEAREST
Certified copy is filed with the county building inspection CROSS ST
Residential Swimming Pools
department OWNER OR
FIRM NAME C C C V
Date Applicant Outlets Rec,Light/ SW 3 PI A ADDRESS t
CERTIFICATE OF EXEMPTION FROM WORKERS' First 20
COMPENSATION INSURANCE Total No Additional CITY C� r t Tel No
PLAN CHECK d
(This section need not be completed if the work involved APPLICANT O
by the permit is for one hundred dollars ($100) or less) Lighting Fixtures First 20 ADDRESS U
Total No / Additional
I certify that in the performance of the work for which this Fixed Appliances Not Over 1 HP CITY Tel No 0
permit is issued, I shall not employ any person m any manner PERMIT (~j
so as to become subject to the Workers' Compensation Laws Range_ Heater_D W APPLICAN Q W
CL
Oven _ Dryer_W M ADDREb> U)
_ pp
Top _ FAU —W H
Date A lican Hood — Fan _Other_ CITY ^ L Tel No ,q Cf /
NOTICE TO APPLICANT If, after making this Certificate of Dlsp _ Room Air Cond_ LICENSE OR
Exemption, you should become subject to the Workers' REG NUMBER d Class
Compensation provisions of the Labor Code, you must forth- Power Apparatus& Large Appliances DISTRICT NO P Y
with comply with such provisions or this permit shall be
deemed revoked Size&Type HP,KW, KVA,or KVAR
Up to 1 Incl
J
Over 1 to 10 Incl DATE
LICENSED CONTRACTORS DECLARATION Over 10 to 50 Incl /0 6 VALIDATION
r�L� ,
I hereby affirm that I ami licensed under provisions of Chapter Over 50 to 100 Inc FINAL
9 (commencing with Section 7000)of Division 3 of the Bush Over 100 BY —
ness and Professions Code, and my license is in full force and
effect
;��������/��,,�/� _ Services
License Number.?7 h"0 Lic Class 9— /
— / 0 200 Amp Under 600 V
201-1000 Amp Under 600 V
Contractor hAMOA/ Date ZIAQ 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 Circuits
License Law for the following reason (Section 7031 5, Busi Additional Sign Branch Circuits
ness and Professions Code)
Misc Conduits&Conductors '
❑ 1, as owner of the property, will do the work and the Other (See Complete Fee Schedule)—
structure is not intended or offered for sale (Section
7044, Business and Professions Code)
CONSTRUCTION LENDING AGENCY l 6 0.3 A
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is PERMIT FEE (Sub-Total) # 0 0 0 0 o 2
issued (Sec 3097,Civ C)
Lender's Name
PLAN CHECKING FEE (One-Fourth Permit Fee) 2 0 0 111,00
Lender's Address PERMIT ISSUING FEE o 0 0
I certify that I have read this application and state that the TOTAL FEE O a�17_8 O
above information is correct I agree to comply with all County I ZZ
ordinances and State laws regulating Electrical wiring, and
hereby authorize representatives of this County to enter upon
the above-mentioned property for inspection(purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature-of P rttee D e