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HomeMy Public PortalAbout9034 BROADWAY_Electrical__ 76A663C- CES06B 12/75 APPLICQTI®V V FOR ELECTRICAL R0CAL Y IJY NIT �JILdI NG AND SAFET /VISION FOR APPLICANT TO FILL IN JOB New Residential Bldgs. & Pools EACH NO.1 FEE ADDRESS a 1 &2 Finaily Sq. FL $ - $ - LOCALITY Multi-family Sq. Ft. - NEAREST Residential Swimming Pools CROSS ST. e L< OWNER OR FIRM NAME r Outlets: Light, Switch& Receptacle MAI L First 20 ADDRESS" Io ar Additional CITY /�'A1 L� Tel. No. PLAN CHECK APPLICANT Lighting Fixtures �- First 20 ADDRESS Additional, J CITY Tel. No. PERMIT Fixed Appliances Not Over 1 HP APP LICANTq Range_ Heater_ D.W. ADDRESS .: a Oven Dryer W.M. /Ej - �, Top FAU W.H. CITY G Tel. No. �9 Hood Fan LICENSE 09 REG. NUMBER 3l� S ��77�� o Disp. A.C. Class U I THAT I HAVE THIS AI'LICITIIN O TO E.YLY Power Apparatus& Large Appliances RDI ES AND STATE OAGREEAND STATE THAT THE ABOVE IS CORRECT AND LAWS REGULATIN w Size&Type HP, KW, KVA,or KVAR ELECTRICAL WIRING. Up to 1 Incl. ET DENTiRT THAI I AN 1E.10EL1 REGISTERED AND/OR Over 1 to 10 Incl. LICENSED AES — CALIFORNIA OR GFLOWNER OR THE ABOVE Over 10 to 50 Ind. ASCRie Eo BEs-eTY AND STATE OF H TIAL PROBE Over 50 t0 100 Incl. PERMIT EE Over 100 SIGNATU v DISTR16T NO. P C SED PAY Services 1O/ u 0-200 Amp. Under 600 V " `6' (� 201 - 1000 Amp. Under 600 V APPROVALS DATE INSPECTOR'S Over 1000 Amp,or Over 600 V SIGNATURE TEMP. POWER POLE Temp. Power Pole&Appurtenances UNDERSLAB WORK Sign with One Branch Circuit ROUGH CONDUIT Additional Sign Branch Circuits (Other) WIRING FIXTURES POWER AUTHORIZED PERMIT FEE (Sub-Total) UTILITY CO.NOTIFIED PLAN CHECKING FEE (One-Fourth Permit Fee) FINAL PERMIT ISSUING FEE NATES TOTAL FEE f �� PLAN CHECK VALIDATION CK. M.O. P RMIT. LIDAT�N CK M.O. CASH CASH 3 4''9,J�AN :� L - 9.0 0 A56 - 1 1 . 1111 ` - ; 1%A • WORKERS'COMPENSATIONDECLARATION 76A663 APPLICATION FOR ELECTRICAL PERMIT 1 - CE-806G (2801 6 I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY insure, or a certificate of Workers'Compensation Insurance,or a-certified copy thereof(Sec. 3800, Lab.C.) " FOR APPLICANT TO FILL IN SOB ADDRESS qq Policy No. Company - EACH NO. FEE pJ 4 E', E(^ New Residential Bldgs.&Pools d ,a-LsI ❑ Certified copy is hereby furnished. 1 &2-Family,Sq. Ft. $ — S LOCALITY ,�o '�i �•� I ❑ Multi-family Sq. Ft. NEAREST ((// Certified COPY is filed with the county building inspection CROSS ST MQQ department: Residential Swimming Pools �/ OWNER OR ] y� p `f' FIRM NAME Illi Cil MDS Dale Applicant Outlets: Rea.9L Light l�y�l,SW, MAIL qD 1 �•/ Firsf2 ADDRESS JV3 G• LJ)` (,C H CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. COMPENSATION INSURANCE ---F/-yV- Additional CITY /,0 ��-�� Tel N A ' PLN CHEC j d (This section need not be completed if the work involved APPLICANT - OU by the permit is for one hundred dollars (SI00) or less.) Lighting Fixtures . First 20 ADDRESS - Total No. [7L Additional cc I certify that in the performance of the work for which this CITY .' Tel No. O •I Fixed Appliances Not Over 1 HP y�J F- permit is issued. shall not employ any person in any manner 1 1I'e/n OS so as to become subject to the Workers' Compensation Laws. Range_ HeaterPERMIT w _D.W. _ APPLICANT 1 I 'I y Oven Dryer_W.M. ADDRESS Z Date Applicant Top FAU _W.H. — I-r Hood _'Fan .—Other_ CITy g t Tel No. NOTICE TO APPLICANT: If, after making this Certificate of Oisp. — Room Air Cond._ LICENSE URI I - Exemption, you should become subject to the Workers' - REG. NUMBER Class Compensation provisions-of the Labor Code, you must forth- Power Apparatus& Large Appliances DISTRICT NO. - PROC SED BY- with comply with such provisions or this permit shall be - j deemed revoked. Size&Type HP,KW, KVA,or KV An -1 o y Up to.1 Incl. 4 Over 1 to 10 Incl. FINAL LICENSED CONTRACTORS DECLARATION DATE/O-(� Q- VALIDATION. Over 10 to 50 Incl. I hereby affirm that 1 am licensed under provisions of Chapter Over 50 to 100 Inc. 9 (commencing with Section 7000) of Division 3 of the Busi- Over 100 BFINAL y ness and Professions.Code, and my license is in full force and I effect. Services License Number Lie. Class 0-200 Amp.Under 600 V " 1 i 201-1000 Amp. Under 600 V - Contractor Date 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 Circuit 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 _ 1 8 1 A 7044, Business and Professions Code). _ CONSTRUCTION LENDING AGENCY - t e e e a e I hereby affirm that there is�a construction lending agency - for the performance of the work for which this permit-is pERMITFEE (Sub-Total) issued (Sec. 3097,Civ.C:). . - / Lender's Name - PLAN CHECKING FEE (One-Fourth-Permit Fee) U Lender's Address 'PERMIT ISSUING FEE 071,0-80 I certify that I have read this application and state that the TOTAL FEE , above information is correct. 1 agree to comply with all County ordinances and State laws,regulating Electrical wiring, and hereby authorize representatives u�this County to enter upon , the above-mentioned property f (inspection purposes. SEE REVERSE FOR EXPLANATORY-LANGUAGE 4D.1Signature of Yermitte - TION DEC TION WORKERS'that I have a cerci cafe of corse '76W1GaPw3i9> APPLICATION FOR ELECTRICAL PERMIT I hereby affirm that I have o certificate of consent to self �cEqW ' 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. Company FOR APPLICANT TO FILL IN JOB ❑Certified copy is hereby furnished. New Residential Bldgs. 8 Pools EACH NO. FEE ADDRESS Certified copy is filed with the county building inspec- 18 2-Family, Sq. Ft. $ — $ LOCALITY tion department. Multi-family Sq. Ft. — NEAREST Residential Swimming Pools CROSS ST. Date Applicant OWNER OR FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: RecLightSwMAIL I� COMPENSATION INSURANCE _ _ _ ._ _ ADDRESS I/ (This section need not be completed if the work involved byFirst 20 CITY the permit is for one hundred dollars ($100)or less.) Total No. Additional Tel. No. I certif that in the performance of the work for which this- PLAN CHECK Y P APPLICANT permit is issued, I shall not employ any person in y monner so as to b co e subject to, Worke Compe do ws. Lighting Fixtures First 20 ADDRESS Additional Date Applicant Total No. CITY Tel. No. NOTICE TO APPLICANT: If, after making this a icate Fixed Appliances Not Over 1 HP pERMIi Exemption, you should become subject to the Range— Heater—D.W. _ APPLICATION Compensation provisions of the Labor Code, you must forth- Oven — Dryer _W.M._ ADDRESS It,5.22 .J' with comply with such provisions or this permit shall be Top — FAU —W.H. — deemed revoked. Hood — Fan —Other_ CITY Tel. No. LICENSED CONTRACTORS DECLARATION LICENSE OR Disp. _ Room Air Cond. — Class. 'I hereby affirm that I am licensed under provisions of Chapter 9 REG. NUMBER C- ( commencing with Section 7000)of Division 3 of the Business Power Apparatus 8 Large Appliances DISTRICT,NP. _/ pR SSEp >_ and Professions Code,and my license is in full force and effect. Type (r�,/ ,/j_ O Size & T e HP, KW, KVA, or KVAR (� License Nur4AOALic. Class _L � U Up to 1 Incl. FINAL Contractor Date Over 1 to 10 Incl. DATE VALIDATION p ❑ Over 10 to 50 Incl. FINAL 7 F_ I am exempt un r ec. Over 50 to 100 Inc. BY / W 100 .&P C. for this reason� Over ( � 100a - Services,Sices, Swbd., MCC 8 Ponelboards Date: 0- 200 Amp. Under 600 V D'� Z Signature 201 - 1000 Amp. Under 600 V ❑ Exemption for Reg. Mainz. Elect. Over 1000 Amp, or Over 600 V SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Temp. Power Pole 8 Appurtenances 1 herebyaffirm tliat I am exempt from the Contractor's License Sign with One Blanch Circuit a P ACC:T.4 . Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits ... . ._ .,. Professions Code): 3307 20,00 ❑ I, as owner of the property, will do the work and the Misc. Conduits 8 Conductors 1 ITEMS structure is not intended or offered for sole(Section 7044, Other (See Complete Fee Schedule)— Business and Professions Code). � ' TOTAL 20 .00 CONSTRUCTION LENDING AGENCY CHECK 20,1 I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) C'HAN6E ,QO (Sec. 3097, Civ. C.). ' PLAN CHECKING FEE Lender's Name - 3 V 00011-0001 27 1/91.1PERMIT ISSUING FEE (�(/ Lender's Address o 807 10 1 AMli,19 I certify that I have read this ication and state that the TOTAL FEE above information is correct. a to comply with all County - ordinances and State laws re sit tin Electrical wiring, and hereb authorize re entat' e o is County to enter upon the ve-mentio d rap y spection purpo s. SEE REVERSE FOR EXPLANATORY LANGUAGE Si nature of Permittee at �� ©s