HomeMy Public PortalAbout9468 BLACKLEY ST_Electrical__ 76A669C- CEe06B I2/75 APPLICATION FOR ELECTRICAL PERMIT _
'BUILDING AND SAFETY DIVISION t
FOR APPLICANT TO FILL IN JOB
rResid6ential
Bldgs & Pools EACH NO FEE ADDRESS
Sq Ft. $ — $ LOCALITY I G
q Ft. — ' NEAREST �.r
CROSS ST
wimming Pools OWNER OR
''�7— ,�. FIRM NAME
Outlets Light, Swh & Re-
Outlets, t MAI L
First 20 ADDRESS ,
Additional CITY , Tel No
-h PLAN CHECK '
Lighting Fixtures APPLICANT
First 20ADDRESS
Additional, CITY Tel' No
PERMIT
Fixed Appliances Not Over 1 HP APPLICANT
Range Heater_ D.W
Oven Dryer W M ADDRESS
Top FAU W H CITY el
Hood "Fan LICENSE OR a
Dis A C REG NUMBER Class U
P
' 1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION =
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY Q
Power Apparatus& Large Appliances WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING V
Size&Type HP, KW, KVA,or KVAR ELECTRICAL WIRING ly
a..
cn
Up to 1 Incl 1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR Z
Over 1 to 10 Incl LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE
Over 10 to 50 Incl DESCRIBED RESIDENTIAL PROPER
- o
Over 50 to 100 Incl PERMITEE
Over 100 SIGNATUR an
c DISTRICT NO PR CES D BY
Services
0-200 Amp. Under 600 V O ���'
201 - 1000 Amp Under 600 V APPROVALS E INSPECTOR'S
SIGNATURE
Over 1000 Amp or Over 600 V -
TEMP POWER POLE Q
Temp Power Pole&Appurtenances UNDERSLAB WORK [ 7�
Sign with One Branch Circuit
Additional Sign Branch Circuits ROUGH CONDUIT
(Other) W I R IN
FIXTURES
POWER AUTHORIZED
PERMIT FEE (Sub-Total) UTILITYCO NOTIFIED
PLAN CHECKING FEE (One-Fourth Permit Fee) t�
FINAL
PERMIT ISSUING FEE
NOTES
TOTAL FEE •S
PLAN CHECK VALIDATION CK MO CASH PERMIT VALIDATI CK MO CASH
43 3 AUG. 8.50 ,&;6
s WORKERS' COMPENSATION DECLARATION 4 "zo-ooteDPW sia7 APPLICATION FOR ELECTRICAL PERMIT ,O
1;e1 he;'et,� affirm that I have a certificate,of consent to self CE-806G /�
insure,,or a certificate,of Workers' Compensation Insurance, COUNTY OF LOS ANGELES - DEPT.)OF PUBLIC WORKS /or a certified copy thereof (Sec 3800, Lab C )
Policy No J Company f FOR APPLICANT TO FILL IN JOB ADDRESS ei e
ElCertifiedcopy is hereby furnished New Residential Bidgs & Pools EACH NO FEE ✓
❑Certified copy is filed with.the county building inspec- 1 & 2-Family, Sq Ft $ — $ LOCALITY
tion deportment / Multi-family Sq Ft l NEAREST
CROSS (At y 10 _7T1
1 Residential Swimming Pools- OWNERS
Date OR
Applicant
e FIRM NAME
,CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets Rec Light Sw_- 'MAIL
COMPENSATION INSURANCE -ADDRESS J S� i
First 20
(This section need not be completed if the work involved by TotaINNO Additional CITY,, I e Tel No
the permit is for one hundred dollars ($100)or less.) PLAN CHECK
I certify that in he performance of the work for which this APPLICANT -
permit is issued, I shall not employ any person in any manner I Lighting Fixtures First 20 ADDRESS
so as to become subject to the Workers'Compensation Laws
� " ''tt ��((//��• /; Total No Additional CITY Tel
- -
DateApplicant ��/ '
NOTICE O APP ANT If, after making .this Certificate of Fixed Appliances Not Over 1 HP PERMIT
(C
APPLICATION
—
Range Heater—D W
Exemption, you should become subject to the Workers' 9
Corr pensotion'provisio'ns of the Labor Code, you must forth- Oven — Dryer —W M — ADDRESS C
with comply with such provisions or this permit shall be=', Top FAU —W H-—
deemed revoked Hood — Fan —Other— CITY �f Tel No
LICENSED CONTRACTORS DECLARATION LICENSE OR
Disp — Room AinCond Class
I hereby affirm that I am licensed under provisions of Chapter 9 REG NUMBER
(commencing with Section 7000)of Division 3 of the Business Power Apparatus& Laige Appliances DISTRICT NO PROCE ED BY d
and Professions Code,and my license is in full force and effect { /}�
Size &Type HP, KW, KVA, or KVAR' 0
License Number Lic Class Up to 1 Incl FINA
Over 1 to 10 Incl DAT ALIDATION O1
Contractor" - Date Over 10 to 50 Incl - FIN ~
❑ I am exempt under Sec. Over 50 to 100 Inc BY 4 W
W
B &P C for this reason' Over 100 t1
Services, Swbd , MCC & Panelboa}ds Z
Date 6-200 Amp Under 600 V
am� Z
Signature 201 - 1000 Amp Under 600 V ;
,E] Exemption
1000 Amp or Over 600,V-
Exemption for Reg Mamt Elect �
SINGLE FAMILY Temp Power Pole &Appurtenances
HOME OWNER-BUILDER DECLARATION 2,,0,2 3 5 A
I hereby affirm that I am exempt from the Contractor's License Sign with One Branch Grcuit
Law for the following reason (Section 7031 5, Business and Additional • e Sign Branch Circuits - # 2,
Professions Code) I - -
{']� Misc Conduits&Conductors' �• e 2 5.'5 0
LTJ 1, as owner of the property, will do the work and the `, _
` structure is not intended or offered for sale(Section 7044, Other (See Complete Fee Schedule)— a;e-.2 5.5,0 v
Business and Professions Code)
CONSTRUCTION LENDING AGENCY 0 72D—8 8
,I hereby affirm that there is a construction lending agency for '
the performance of the work for which this perms issued PERMIT FEE r (Sub-Total)
(Sec 3097, Civ C )
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE
Lender's Address 11
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 t "
ordinances and State jaws regulating Electrical wiring, and -
hereby authorize representatives of-this County to enter upon
the above-mentioned prop rty f r inspection*purposes
r "SEE REVERSE FOR EXPLANATORY LANGUAGE ,
Signature of ermittee Date