Loading...
HomeMy Public PortalAbout9465 BLACKLEY ST_Electrical__ 76A663 CE 806(6/78) a APPLICATION FORILECTRICAL PERMIT COUNTY OF LOS ANGELES BUILDING AND SAFETY FOR APPLICANT TO FILL IN JOB New Residential Bldgs &Pools EACH NO FEE ADDRESS 1 &2 Family Sq Ft $ 025 — $ LOCALITY�� G' Multi family Sq Ft 02 — NEAREST CROSS ST if Residential Swimming Pools 25 00 OWNER OR �7 FIRM NAME ♦ 4J Outlets Rec L ght Sw MAIL First 20 50 ADDRESS Total No Additional 30 CITY C Tel No PLAN CHECK/ APPLICANT Lighting Fixtures First 20 S0 ADDRESS Additional 30 Total No CITY Tel No Fixed Appliances Not Over 1 HP PERMIT_ Range_Heater_D W APPLICANT , Oven—Dryer_W M— ADDRESS 8'4 7 Top _FAU _W H CITY Q�6�.� Tel No 791".", Hood-- Fan _Other_ LICENSE OR .r Disp —Room Air Cond _� 2 50 :510 REG NUMBER ��6 Class C-id IHEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICA Power Apparatus&Large Appliances TION AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO Size&Type HP, KW KVA,or KVAR COMPLY,WITH ALL COUNTY ORDINANCES AND STATE LAWS yp2 50 REGULATING ELECTRICAL WIRING Up to 1 Incl I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR Over 1 to 10 Incl 5 00 LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF 1 Over 10 to 50 Incl 12 50 CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE Over 50 to 100 Inc 25 00 1 DESCRIBED RESIDENT AL PR PERTY 40 00 PERMIT EE Over 100 SIGNATURE �� Services FINF OCESS BY0 200 Amp Under 600V 12 50 A 201 1000 Amp Under 600 V25 00Over 1000 Amp or Over 600 V 5000 Z Lo- 3 � g Temp Power Pole&Appurtenances 1000 4Sign with One Branch Circuit 1000 C Additional Sign Branch Circuits 200 ION > Misc Conduits&Conductors TION v 100o ERSE z 26 99,2 A Other(See Complete Fee Schedule) v Z # ooaoo2 2002200 PERMIT FEE (Sub Total) o o o 2 Z 0 0 v PLAN CHECKING FEE (One Fourth Permit Fee) O s + � I Q02—'79 PERMIT ISSUING FEE $7 00 G J TOTAL FEE 2 2 V > INSPECTION FINALED o�c W , dote 141) -/®s` 7 By ©s 7GA669_CE806-9-57 APPLICATION F®R ELECTRIC PERMIT 1 COUNTY OF LOS ANGELES DEPARTMENT OF COUNTY ENGINEER BUILDING n BUILDING AND SAFETY DIVISION ADDRESS L JOHN A LAMBIE COUNTY ENGINEER f "r� CASSATT D GRIFFIN SUP T OF BUILDING LOCALITY LLC IS / NEAREST FOR APPLICANT TO FILL IN CROSS ST PERMIT FEES I T E M NUMBER EACH FEE OWNER �j- OUTLET / 2 S S MAIL LIGHTS RECEPT SW 10 ADDRESS LIGHTING FIXTURES 10 CITY TEL NO ELEC RANGES CLO DRYERS ELECTRICIAN A elra WATER HEATERS 50 ADDRESS Oo �� & ELEC SPACE HTRS DISHWASHERS n/� �^ GARBAGE DISPOSERS AUTO- CITY /T TEL NO d STATE WASHERS STA COOKING UNITS 25 LICENSE NO MOTORS OVER INC H P DISTRICT NOGR ZONE READY FOR INSPECTION O — 1/2 25 1/2 — 2 so INSPECTION RECORD 2 — 5 100 5 — 15 ISO 1 �- 15 — 50 250 SO— 200 500 SIGNS NO TRANS NO LAMPS SERVICE O 600V 1 00 SERVICE OVER 600V 500 MISC WIRING PERMIT 1 00 FIXTURE PERMIT 100 Q O SUPPLEMENTARY PERMIT 50 TOTAL FEE $ G APPROVALS I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION DATE INSPECTOR S SIGNATURE AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CONDUIT WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING r ELECTRICAL WIRING WIRING 1 HEREBY CERTIFY THAT I AM PROP REG T D AND/OR LICENSED AS REQUIRED BY LOS AN C UN T IS STATE OF FIXTURES CALIFORNIA OR THAT I AM T NE THE ABOVE POWER DESCRIBED RESIDENTIAL PR A SIGNATURE UTILITY CO NOTIFIED OF PERMIT TE FINAL VALIDATION ARTHUR C VEIT. --� SUPERVISING ELECTRICAL NGINEER CK MO CASH !coo 1- st 2 7 2 A 6100 M 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 ENGINEER / - t WILLIAM A.JENSEN, SUPT OF BUILDING LOCALITY NEAREST FOR APPLICANT TO FILL IN CROSS ST. RECEPT. TOTAL NO. EACH FEE OUTLETtl7 FIRST 20 ' J S 20 $ OWNER LIGHT '-" " o� MAIL ADD'L 10 ADDRESS SWITCH. OVER 20 LIGHTING TOTAL FIRST 20 ,20 CITY TEL. NO. FIXTURES �� A.DIL 10 ELEC 111 TRICIAN ovFR 20 RANGES CLO.DRYERS WTR.HTRS. 1,00 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. DISTRACT O. GROUP E PRQCJZSSED BY O 1 1.00 �' i I 3 1.50 INSPECTION RECORD 3 s 2.00 8 15 2.50 15 50 3.00 n}. 50 100 5.00 0 SIGNS: NO.TRANS NO.LAMPS 0 O SERVICE O.600V-NOT OVER 200A 1.00 LJ w SERVICE 0-600V-OVER 200 A. 2.00 N SERVICE OVER 600V 5.00 z MISC. PERMIT ISSUING FEE 2.00 SUPPLEMENTAFtY PERMIT ISSUING FEE 1.00 TOTAL FEE $ � r 1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APP LI AT ION APPROVALS DATE INSPE 'S SIGNATURE AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO OMPLY CONDUIT WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ELECTRICAL WIRING. WIRING F IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR L LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF FIXTURES CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE - DESCRIBED RESIDENTIAL ROPE Y. POWER SIGNATURE r UTILITY CO.NOTIFIED OF PERMITTE FINAL )�LIDATION A C. VEIT SUPERVISING ELECTRICAL ENGINEER �clf) MO CASH LI Nuo L&O3 99 DEC 19 2 D 9.7 G- �- FGA663 CE806,10 6r r; APPLICATION FCk ELECTRICAL PERMIT —Z • COUNTY OF LOS ANGELES DEPARTMENT OF COUNTY ENGINEER BUILDING BUILDING AND SAFETY DIVISION ADDRESS JOHN A LAMBIE, COUNTY ENGINEER WILLIAM A JENSEN, SUP T OF BUILDING LOCALITY NEAREST FOR APPLICANT TO FILL IN CROSS ST I T E M NO I EACH FEE OUTLETS (FIRST 20) $20 $ OWNER LIGHTS I RECEIPT SW MAIL OUTLETS (ADD L UNITS) 10 ADI)RESS LIGHTS RECEPT SW LIGHTING FIXTURES (FIRST 20) / 20 a CITY TEL NO 414 t4L LIGHTING FIXTURES (ADDITIONAL) 10 ELECTRICIAN RANGES CLO DRYERS- WTRH�TRS 100 ADDRESS GARB DISP STA COOK%`''*6(/IO CITY TEL` NO DISHWASH AUTO WASH `(� STATE SPACE HTRS STA APP (+/s H P MAX ) 50 l LICENSE N 1 MOTORS OVER NOT OVER H P DISTRICT NO GROUP Z E PROCESSED BY O 1 100 �, bd v Oo� _� - 1 3 150 INSPECTION RECORD 3 8 200 B• 15 25 4 15 50 300 /, ! O s 50 100 500 J /`7 r A,��,�meq• .; SIGNS NO TRANS / h NO LAMPS O,Y— �/� �/�� z SERVICE O 600V NOT OVER 200A 100 SERVICE O 600V OVER 200 A 2 00 J SERVICE OVER 600V Soo MISC PERMIT ISSUING FEE 200 UU SUPPLEMENTARY PERMIT ISSUING FEE 100 TOTAL FEE JSTATEOF HEREBY ACKNOWLEDGE THAT I HAVE READ THIS AAPPROVALS � DATEEINSPECTORS SIGNATUREAND STATE THAT THE ABOVE IS CORRECT AND AGREE CONDUIT `I% !f '! �WITH ALL COUNTY ORDINANCES AND STATE LAWS ELECTRICAL WIRING WIRING `HEREBY CERTIFY THAT I AM PROPERLY REGISTERLICENSED AS REQUIRED BY LOS ANGELES COUNTY ANFIXTURESCALIFORNIA OR THAT I AM THE LEGAL OWNER OF / DESCRIBED RESIDEN IA PROPERTY POWER SIGNATURE UTILITY CO NOTIFIED OF PERM ITTE FINAL VALIDATI9N- / ARTHUR C VETT CK MO CASH SUPERVISING ELECTRICAL ENGINEER CK MID CASH pr 5 7GA663-CES06 5-66 APPLICATION FOR ELECTRIC PERMIT 1 COUNTY OF LOS ANGELES DEPARTMENT OF COUNTY ENGINEER BUILDING BUILDING AND SAFETY DIVISION ADDRESS JOHN A LAMBIE, COUNTY ENGINEER CASSATT D GRIFFIN,SUPT OF BUILDING LOCALITY FOR APPLICANT TO FILL IN cNEAREST / PERMT FEES Ile Ross sT I T E M ' NUMBER EACH FEE OWNER OUTLETS $ $ MAIL LIGHTS RECEPT SW 10 ADDRESS LIGHTING FIXTURES 10 CITY TEL NO ELEC RANGES CLO DRYERS ELECTRICIA 'WATER HEATERS 50 ADDRESS ELEC SPACE HTRS DISHWASHERS CITY NO Cj4!1 E DISPOSERS AUTO- _ STATE WASHERS STA COOKING UNITS 25 LICENSE NO MOTORS OVER INC H P DISTRI T NO GROUP ZON P ESSED BY 0— 1/2 25 1/2— 2 so INSPECTION RECORD 2— 5 100 5— Is 150 is— 50 250 50-200 500 SIGNS NO TRANS NO LAMPS SERVICE 0-600V too SERVICE OVER 600V Soo MISC WIRING PERMIT too �- FIXTURE PERMIT too- SUPPLEMENTARY 00-SUPPLEMENTARY PERMIT 50 TOTAL FEE IHEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS A LICATION APPROVALS DATE INSPECTOR'S SIGNATURE AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING CONDUIT ELECTRICAL WIRING 1 HEREBY CERTIFY THAT'I AM PROPERLY REGISTERED AND/OR WIRING LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF FIXTURES " CALIFORNIA OR THAT I AM THE LEGAL OWNER F THE ABOVE DESCRIBED RESIDENTI PROP POWER SIGNATURE UTILITY CO NOTIFIED -I(. OF PERM ITTE;: Rim- FINAL YJ I7"'T" `� / ✓� ®a V JIDATION ARTHUR C VEITF (�CK� Mo CASH SUPERVISING ELECTRICAL ENGINEER Ab0 3 2 1 1 SEP 2 g 2 A 1 .8 5 to rp TEMPLE CITY 73A669-CE60610-52 APPLICATION FOR ELECTRIC PERMIT 1 COUNTY.OF LOS ANGELES DEPARTMENT OF COUNTY ENGINEER BUILDING /�y BUILDING AND SAFETY DIVISION ADDRESS fnf/ JOHN A. LAMBIE. COUNTY ENGINEER e WILLIAM A JENSEN SUP T OF BUILDING LOCALITY 'Pi FOR APPLICANT TO FILL IN NEAREST PEPMW FEES CROSS ST D Il y OWNER ' =4."-- ITEM NUMBER EACH FEE MAIL OUTLET $ f0 $ q .y ADDRESS C�G LIGHTS RECEPT SW �X- 6 LIGHTING FIXTURES 10 CITY TEL NO ELEC RANGES CLO DRYERS ELECTRICIAN WATER HEATERS 5O ADDRESS ELEC SPACE HTRS DISHWASHERS CITY IR I TEL NO GARBAGE DISPOSERS AUTO-- STATE WASHERS STA COOKING UNITS 25 LICENSE NO MOTORS OVER INC H P DISTRI T GROU N P CESSED BY O— 1/2 25 1/2- 2 50 INSPECTION RECORD 2— 5 100 `5— 18 150 IS— 50 250 50-200 Boo SIGNS NO TRANS NO LAMPS SERVICE 0-600V 100 SERVICE OVER 600V Boo MISC WIRING PERMIT 100 ✓ FIXTURE PERMIT 100 SUPPLEMENTARY PERMIT 50 TOTAL FEE $ I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION APPROVALS DATE INSPECTOR'S SIGNATURE AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING CONDUIT ELECTRICAL WIRING WIRING 6t'�/� I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF FIXTURES CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE DESCRIBED RESIDENTIAL ROPERT POWER SIGNATURE UTILITYCO NOTIFIED I . OFPERMITTEE VT y }/,r r✓ / i i ,�,r FINAL OF DATION ARTHUR,C VEIT, CK A MO CASH SUPERVISING, ELECTRICAL ENGINEER l 0 1 I WORKER'S COMPENSATION DECLARATION 20.0019 DPW(12-91) AP 'LICAAT4'ON 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. copy thereof-(Sec.3800 Lab. C.) Polis No. Company FOR APPLICANT TO FILL IN qk� < /t^ [�❑ Y P Y DDRESS N-V.T� Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE LOCALITY El 1 &2-Family,Sq.Ft. _ $ $ Certified copy is filed with the county building inspection NEAREST department. Multi-family Sq.Ft. C ROSS ST. Date Applicant Residential Swimming Pools ASS BOOK PAGE PARCEL CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec. Light Sw. FFIIROF M NAME C COMPENSATION INSURANCE LL First 20 MAIL (This section need not be completed if the work involved by the Total No. Additional s ADDRESSf ,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 become subject to the Workers' Compensation Laws. Lighting Fixtures First 20 PLAN CHECK APPLICANT . Total No. Additional ADDRESS Date Applicant �5A,0414� �� �✓� NOTICE TO APPLICANT: If, after making this Certificate of RESIDENTIAL APPLIANCES NOT OVER 3 HP. CITY 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 p p Y Power Apparatus&Large Appliances APPLICANT G{' provisions or this permit shall be deemed revoked. LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS I 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,and my license is in full force and effect. Over 10 to 50 Incl. LICENSEClass. Over 50 to 100 Incl. REG.NUMBB ER 0- a Over 100 DISTRICT NO. SSED BY 0 License Number Lic.Class _ �{''� � � (� Services, wb MC &Panelbcards �� - 9'4Under 600 V FINAL Q Contractor Date DATE ` ❑ 400-1000 Amp. Under 600 V ^1 1 am exempt under Sec. VALIDATION V .Over 1000 Amp.or Over 600 V FINAL W B.&P.C.for this reason BRANCH CIRCUIT FEES BY W Date: 15A,or 20A, 1,20V,Lighting or Recept. Z_ 1 To 10 Branch Circuits ! Signature 11 To 40 Branch Circuits - a El 41 Or More Branch Circuits Exemption for Reg.Maint.Elect, 15A,20A,208V To 277V Lighting Br.Circuits U 46 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 Cod _ ,-:_r•-:.;Y, s_, •=T: 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) LIU and Professions Code). CONSTRUCTION LENDING AGENCY ; ,)J_.i' f r .- _, tlaW . I hereby affirm that there is a construction lending agency for the AA performance of the work for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total) /f�7 J---• _ a Civ.C.) PLAN CHECKING FEE 01 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 and State laws regulating Electrical wiring,and hereby authorize representatives of th a,County to enter upon the above-mentioned property for in ction pure S. SEE REVERSE FOR EXPLANATORY LANGUAGE 0e .5--1 - SIGNATURE OF PER MI DATE WORKER'S COMPENSATION DECLARATION 720 6A663 DPW If 91) APPLICATION FOR ELFECTRICAL PERMIT 76A663 I hereby affirm that I have a certificate of consent to self Insure, � or a certificate 6f Worker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV copy thereof((Sec 3800 Lab C) ? Policy NOy 5-2 Company�i �2r�� �-4 FOR APPLICANT TO FILL IN JOB ADDRESS ( t7 f' Certified copy Is hereby furnished New Residential Bldgs &Pools NO EACH FEE $ $ LOCALITY ��}T ie ❑ Certified co Is filed with the count bulIdin inspection, 1 &2-Family,Sq Ft PY 9 P NEAREST ; department Multifamily Sq Ft CROSS ST G Lco Residential SwimmingPools v Date Applicant ASSESSOK MAP PAGE PARCEL CERTIFICATE OF EXEMPTION FRQP WORKERS Outlets Rec _Light Sw FlPM NAME �C- �jq G49M COMPENSATION INSURANCE r, Flrst 20 a MAIL (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 PLAN CHECK become subject to the Workers' Compensation Laws Lighting Fixtures 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 provisions of the Labor Code, you must forthwith comply with such APPLICANT / p provisions or this permit shall be deemed revoked Power Apparatus&Large Appliances G L ” ' '1 LICENSED CONTRACTORS DECLARATION - Size&Type HP,KW,KVA,or KVAR ADDRESS Z3 G C�y �JO I 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 CIT ` zL Tel No U33 5 Professions Code,and my license Is in full force and effect Over 10 to 50 Incl LICENSE B L! �/ Class G / a Over 50 f0 100 Incl REG NUMBER �j /LI 6 C Over 100 DISTRICT NO ROC ED BY O License Number1 Q Lic Class C Services,S�wwb-dd7y.��MCC YPya�nel ards � �� 1 U ^9� ,�2�0-399 Am Under 600 V FINAL 0 V�COntr CtOr Date DAT El 400 1000 Amp Under 600V I am exempt under Sec VALIDATION V Over 1000 Amp Or Over 600 V FINAL / d B&P C for this reason BRANCH CIRCUIT FEES BY /i/ co Date 15A,or 20A, 120V,Lighting or Recept Z_ 1 To 10 Branch Circuits Signature 11 To 40 Branch Circuits ❑ _ 41 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 DECLARATION - A I T°s I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit _ '- for the following reason (Section 7031 5, Business and Professions Additional Sign Branch Circuits D� °C_i Code) i ITEMS ❑ I as owner of the property,will do the work and the structure Misc Conduits&Conductors - t is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) t T t[Tr:,L 61 - 65 and Professions Code) CONSTRUCTION LENDING AGENCY Ll{ I hereby affirm that there is a construction lending agency for the fEr�hi�sE ,f RJ performance of the work for which this permit Is Issued (Sec 3097, PERMIT FEE (Sub-Total) {� ' PLAN CHECKING FEE Lender's Name PERMIT ISSUING FEE O�� ,05*2 - : Lender's Address j 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 and State laws regulating Electrical wiring,and hereby authorize representatives of this County to enter upon the above mentioned property for .action purp SEE REVERSE FOR EXPLANATORY LANGUAGE SIGNATURE OF ERIOITTEE DATE WORKERS' COMPENSATION DECLARATION -663 10/81 APPLICATION FOR ELECTRICAL PERMIT , I hereby affirm that 1-have a certificate of consent to self insure, CE-806G or a certificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY copy thereof(Sec 3800 Lab C) r Policy No Company FOR APPLICANT TO FILL IN JOB ` E] Certifiedcopy is hereby furnished New Residential Bldgs & Pools EACH NO FEE ADDRESS y/ Certified copy is fled with the county budding 'inspection LOCALITY 1 & 2-Family,Sq Ft $ — $ ❑ +depa"rtment Multi-family Sq Ft NEAREST CROSS STV' Applicant " Residential Swimming Pools,, OWNER OR Date pp A > FIRM NAME iCJ CERTIFICATE OF EXEMPTION FROM WORKERS• r ti 4 MAIL Outlets'Rec Light Sw t i m ,• "• COMPENSATION INSURANCE ' �Sr r ..,,.E ' � � � ADDRESS,- �X�-�•'1/( � - (This section need not be completed if the work involved by the first 20 Total No Additional' ' Q CITY_ _, �J Tel No ,permit is for one hundred dollars ($100)or less) � • , '. - , I certify that in the performance of the work for which this permit •PLAN CHECK r to an APPLICANT is issued, I shall not employ y y person in any manner,;,so as to become subject to the Workers'Compensation Laws r, Lighting Fixtures�t! First 20 ADDRESS `5; AAE' Total No ldddional_ C CITY Tel No Date Applicant Fixed AppliancesNot �O1ver 1 HP' t- NOTICE TO, APPLICANT, If, after making this Certificate ,of PERMIT Exemption,you should become subject to the Workers Compensation Range_ Heater_ DW �, T APPLICANT provisions of thefLabor Code, you must forthwith comply„with such Oven Dryer'_fWM ADDRESS { 'provisions or this permit shall be deemed revoked Top FAU W _ _ _ LICENSED CONTRACTORS DECLARATION CITY Tel No Hood Fan er_ I,hereby affirm that I am licensed,under, provisions of Chapter 9 Disp --Room Air Condq �_ - LICENSE OR a REG NUMBER Class (commencing with Section 7000) of Division 3 of the Business-and. �, , Professions Code,and my license is in full force and effectDISTRICT NO + PROCESSE Y- Power Apparatus& Large Appliances � ' Size& Type HP,KW,KVA,or"KVAR License Number Lic ClassUp to 1 Incl FINAL ~U Over 1 to 10 Incl DATE r�,��� 0 Contractor Date FINAL f .VALIDATION U ❑ Over 10 to 50 Incl I am exempt under Sec Over 50 to 100 Inc By__ 1� W B&P C for this reason Over 100 (� N Services, Swbd,MCC& Panelboards Z Date 0-200 Amp Under 600 V Signature 201- 1000 Amp'Under 600 V ' Over 1000 Amp or Over 600 V Exemption for Reg Maint Elect SINGLE FAMILY Temp Power Pole& Appurtenances 2 , HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit g I hereby affirm that I am exempt from the Contractors License Law Additional Sign Branch Circuits ACCT. for the Cod ) following reason (Section 7031 5, Business and Professions R ^3 ra 1OV ��{ Misc Conduits,&Conductor`s ITE�iSS '" Other (See Complete Fee Schedule) y 4 OV I,as owner of the property,will do the work and the structure w1 is'not intended or offered for,sale (Section 7044, Business _ TOTAL - 1-31.80 and Professions Code) hu CONSTRUCTION LENDING AGENCY r CHECK 131`80 1 hereby affirm that there is a construction lending agency efor the CHAKE performance of the work for which this permit is issued(Sec 3097, PERMIT FEE (Sub-Total) Q r Civ C) i' r PLAN CHECKING FEE - 00M-0001 11/20/9` L'ender's Name PERMIT ISSUING FEE - - �� - 1 PM 6.*23 Lender's Address I certify that I have read this application and state that the above ' TOTAL`FEE information is correct I agree to comply with all County ordinances and State laws regulating Ele wiring, and hereby authorize representat ves of this Coun to n er upon the above-mentioned - pr erty o inspect o�purp ses SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date c `