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HomeMy Public PortalAbout9108 BROADWAY_Electrical__ 76A663-CE60612-65 APPLICATION FOR ELECTRICAe PERMIT COUNTY OF LOS ANGELES DEPARTMENT OF COUNTY ENGINEER BUILDING /G cJ ,ls TR,, 1 BUILDING AND SAFETY DIVISION ADDRESS 6 if OL JOHN A. LAMBIE. COUNTY ENGINEER COLEMAN W. JENKINS, SUPERINTENDENT OF BUILDING LOCALITY _ NEAREST © FOR APPLICANT TO FILL IN CROSS ST. RECEPT. TOTAL NO. 1EACH FEE OUTLETS FIRST ZO�S.20 $ —_ OWNER f - W �l LIGHT MAIL p SWITCH ADD'L 10 ADDRESS L7110p ,/IST O OVER 20 / 1 TOTAL FIRST 20 .20 CITY -f P,C G TEL. NO, // LIGHTING l FIXTURES Q FI%TURES J ADD-L 10 CONTRACTOR OVER 201 RANGES DRYERS WTR.HTRS. 1.00 ADDRESS GARB.DISP. STA.COOK CITY TEL. NO. _T DISHWASH. AUTO.-WASH. STATE SPACE HTRS. STA. APDL. .50 LICENSE NO. MOTORS: OVER NOT OVER H.P. Dl! TI JCT N� GR P ZO E P D B O 1 1.00 } 1 s 1.5o INSPECTION RECORD o_ O s — B 2.00 �r U a — 15 2.501 1 '� S� a a . '- _.'-•I O V is 50 3.00 W 6 50 100 15.00 Z SIGNS: NO.TRANS � ,/ L NO. LAMPS ( I// ,(i/f /D! SERVICE 0.60OV-NoT OVER 200A 1.00 ` yj/�I(j /f// SERVICE 0.600V-OVER 200 A. 2.00 SERVICE OVER 600V 5.00 �J G� OTHER (SEE COMPLETE FEE SCHEDULE) PERMIT ISSUING FEE 2.00 SUPPLEMENTARY PERMIT ISSUING FEE 1.00 APPROVALS DATE INSPECTOR'S SIGNATURC TOTAL FEE ®� 1HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION UNDERSLAS WORK AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY ROUGH CONDUIT WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ELECTRICAL WIRING. WIRING 1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR FIXTURES LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF,AND INTEND TO POWER i/ '• RESIDE IN.THE AGO ESCRIBEO RESIDENTIAL Pq OPEflTY. J� SIGNATURE /��y'�/ UTILITY CO.NOTIFIED OF PERMITTEE FINAL VALIDAT� JOSEPH C. ROOHAN CK MO CASH SUPERVISING ELECTRICAL ENGINEER LtD6689% JAN 12 2 D 3.00- Q WORKERS'COMPENSATION DECLARATION CE-563 to/St APPLICATION FOR ELECTRICAL PERMIT {� Nsrebr LR lrm fn3t Fhave a certificate of consent to sell insure, - 806G �J or Is certificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY ,copy thereof (Sec.3800.Lab.C.) Policy NO. Company ,FOR APPLICANT TO FILL IN JOB - ?/,OR �� w - ❑• Certified•copy is hereby furnished. EACH NO. FEE ADDRESS `7 Q • New Residential Bldgs.8 Pools Certified copy is filed witty the county building inspection 1 8 2-Family,Sq.Ft. S $ LOCALITY T puT G/T 'department. Multi-family Sq.Ft. — NEAREST -_)+6 EARESTA E� -(� /1 Date Applicant Residential Swimming Pools `I _OWNER OR'CROSS ST. /'r' /d FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' MAIL COMPENSATION INSURANCE Outlets:RecZZ—Light L Sw.'�D r� co ADDRESS (This section need not be completed if the work involved by the First 20 -J permit is for one hundred dollars($100) or less.) Total No. 47 Additional CITY Tel.No. 1 certify that in the performance of the work for which this permit PLAN CHECK is issued, I shall not employ APPLICANT p y an y person in any manner so as to nn//11 become subject to the Workers' ompensatio`Law 1 Lighting Fixtures First 20 l.{%ADDRESS Total No. D Additional Date Ap c nt CITY Tel.No. NOTICE TO APPLICANT: If, after making this Certificate of Fixed Appliances Not Over 1 HP PERMIT Exemption,you should become subject to the Workers'Compensation Range_ Heater_ D.W. _ APPLICANT provisions of the Labor Code, you must forthwith co I with su Oven _ Dryer _ W.M._ ADDRESS provisions or this permit shall be deemed revoked. & Top FAU — W.H. — LICENSED CONTRACTORS DECLARA ION/ Hood ✓Fan _ Other_ CITY Tel.No. I hereby affirm that I am licensed under previsions ofUapter 9 V LICENSE OR (commencing with Section 7000) of Division 3 of the Business and Disp. Room Air Cond. REG.NUMBER Class. Professions Code,and my license is in full force and effect. Power Apparatus 8 Large Appliances DISTRICT NO. PROLES BY Size 8 Type HP,KW,KVA,or KVAR �J License Number Lic.Class Up to 1 Incl. FINAL Contractor {"�{� o U Over 1 to 10 Incl. DATE [ /G7� OO / VALIDATION 0� Date Over 10 to 50 Incl. F I am exempt under Sec. U FINAL Over 50 to 100 Inc. By �6� W B.BRC. for this reason Over 100 ./--- N Services,Swbd.,MCC 8 Panelboartls D� 'C '-_/-/� 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.Mainl.Elect. ;20039A SINGLE FAMILY Temp.Power Pole 8 Appurtenances o o a o - 2 HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit hereby affirm that I am exempt from the Contractor's License Law Additional Sign Branch Circuits V o - 61.00 for the following reason (Section 703 1.5,Business and Professions Code): ^ ^ - 61.00 I,as owner of the property,will do the work and the structure Misc.Conduits 8 Conductors is not intended C offered for sale (Section 7044, Business Other(See Complete Fee Schedule) D 0 6 2 9_8 8 and Professions Code). 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, Civ.C.). PERMIT FEE (Sub-Total) PLAN CHECKING FEE Lender's Name PERMIT ISSUING FEE U Lender's Address I certify that I have read this application and state that the above TOTAL FEE 6/t 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-menljoned property y�for insssp�pectionuposes. (/ '2� 3 '�! O SEE REVERSE FOR EXPLANATORY LANGUAGE , Signature of PerrAtUde Oate WORKERS'COMPENSATION DECLARATION 20-W19 DPW 3/67 APPLICATION PP ICATIO CI FOR ELECTRICAL PERMITO 6"Llr Ir IL I hereby affirm that I have a certificate of consent to self cr-east insurer or a certificate of Workers' Compensation Insurance, t16" COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS or a cefiified 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 =/i9PLG' e tion department. Multi-family Sq. Ft. — NEAREST CROSS ST. Date Applicant Residential Swimming Pools OWNER OR FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec_Light_5w._ MAIL QQ COMPENSATION INSURANCE First 20 ADDRESS Q/T (This section need not be completed if the work Involved by Total No. Additional CITY — Tel. N �� Q -0 the permit is for one hundred dollars ($100)or less.) PLAN C CK I certify that in the performance of the work for which this APPLICANT VE permit 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 ADDRESS Additional Applicant Total No. CITY Tel. No. Date FixedAppliances NOTICE TO APPLICANT: If, after making this Certificate of Not Over 1 HE PERMIT Exemption, you should become subject to the Workers' Range— Heater—D.W. _ APPLICATION v�isi .(7l Compensation provisions of the Labor Code, you must forth- Oven — Dryer —W.M.— ADDRESS 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. REG. NUMBER Class. I hereby affirm that i am licensed under provisions of Chapter 9 (commencing with Section 7000)of Division 3 of the Business Power Apparatus 8 Large Appliances DISTRICT NO. P ESSED BY d and Professions Code,and my license is in full force and effect. ��_�� Size 8 Type HP, KW, KVA, or KVAR ,�� O License Number Llc. Class Up to 1 Ind. FINAL U DATECr Over I to 10 Ind. �" VALIDATION Cr Contractor Date Over 10 to 50 Incl. NAL I-- FI ❑ I am exempt under Sec. Over 50 to 100 Inc. FI //�� U LU B.BP.C. for this reason Over 100 ! Q. Services, Swbd., MCC 8 Ponelboards Tn Date: DD �/ D Z 0-200 Amp. Under 600 V (m Signature 201 - 1000 Amp:Under 600 V ❑ Over 1000 Amp. or Over 600 V Exemption for Reg. Maint. Elect. SINGLE FAMILY Temp. Power Pole 8 Appurtenances '- HOME OWNER-BUILDER DECLARATION Si n with One Branch Circuit 'a I hereby affirm that I am exempt from the Contractor's License g �t�=j 'T Low for the followingreason Section 7031.5, Business and Additional Sign Branch Circuits .O Professions Code): ( ,1'�LI/ 4` ,�Iii 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 sale Section 7044, Other (See Complete Fee Schedule)_ D 9 mOct Ti ITLS . Business and Professions Code). CHECK T�.(J(- CONSTRUCTION LENDING AGENCY _ I hereby affirm that there is a construction lending agency for CHANGE •�Ill the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) (Sec. 3097, Civ. C.). PLAN CHECKING FEE I]�iI]1]-4iQl]y 2/'217P;I Lender's Name PERMIT ISSUING FEE ✓ _nJtr � Ahl 'v�..K= Lender's Address I certify that I have read this application and state that the TOTAL FEE �d above information is correct. I agree to comply with all County - r 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 ur Signature of Permr ittee Dole