HomeMy Public PortalAbout9647 BROADWAY_Electrical__ 75A663-CE006 9-67 AppLICATlO , FOR ELFT TRICAL PERMIT
-COUNTY OF LOS ANGELES
' .DEPARTMENT OF COUNTY ENGINEER BUILDING7�e
. e 7BUILDING AND SAFETY DIVISION ADDrpg wJOHN A. LAMBIE, COUNTY ENGINEER COLEMANW. JENKINS, SUPERINTENDENT OF BUILDING LOCALITY / e- C1NEAREST _ _FOR APPLICANT TO FILL IN - CROSSST / _ LNO. EACH F.EESSOWNR ECEPT._ MAILLIGHT TOTAL FIRST 20 .20 ADDRESS
SWITCH_ OVER 20 .10 CITY TEL. NQ_LIGHTING 1TOTAL FIRST zo .20 CONTRALTORS C/+ ^1.p:,FIXTURES 1 OVER 20 .1.0 ADO RE55 ��pr /-YC E:� J/e ''jARA NGE_DRY ERLWTR.HTR. CITY � { TEL. NO. �OOT�STA.COOK—OISP. F.A.U.— LICENSE 'NO. 6y6SPACE HTR.—AIR COND. I HEREBY ACKNOE THAT I HAVE READ THIS APPLICATIONANO STATE THAT TOVE IS CORRECT HND AGREE TO COMPLYCLOTHES WASH,_DISHWASH._ WITN ALL COUNTYNA NCES 4N0 STATE LAWS RE GO LATIMGELECTRICAL WIRINGFAN_OTHER I 1,00 QV 1 .HENEBY CERTIAT I AM PROPERLY REGISTERED.AND/ORLICENSED AS REQUBY COS ANGELES COUNTY AND STATE OFMOTORSTRANSFORMERS RATING CALIFORNIA OR THATHE LEGAL OWNER OF, AND INTEND TOIND. HEATERS, ETC. HP. KW. KVA. RESIDEIN, THE E DE SCR IBEO RESIDE AL PROPERTY.
SIZE d TYPE OVER TO SIGNATURE
0 - 1 1.00 OF PERMITTEE
1 - 10 3.00 DISTRI CRqT O. GROU ZO P CE ST40 BY O
10 - 50 5.00 <,S� V i K
O
50 - 100 10.00 NOTES: I.-
100
100 - soo 75.00 a
N
SIGN,GAS SIGN ANO ONE CIRCUIT' - '3.00
TUBE, OR
MARQUEE I ADDITIONAL CIRCUITS 1.00
SERVICE NOT OVER 600 VOLTS OR 200 AMP 2.00
LOUGHCONOUIT
SERVICE OVER 600 VOLTS IJR 200 AMP 5,00 'TEMP SERVICE, POLE, 9 APPURTENANCES 3.00PPROVALS O0.TE JNSPECTOR'S SIGNATURE
POWER POLELAB WORK•CONDUITISSUING FEE 2.00 �- ESSUPPLEMENTARY ISSUING FEE 1.00
AUTHORIZEDPERMIT FEE CO.NOTIFIEDPLAN CHECK FEE (50% PERMIT FEE)
TOTAL FEE JOSEPH. . ROOHAN
SUPERVISING ELE AL ENGINEER
PLAN CHECK VALIDATION CK. M.Q. CASH PERMITVALIDATIONCK. MSO. CASH
LAAO 3 6 .9 6�2 MAR 21 2 D 5'.0 c'),V t
{EE BACK OF APPLICATION FOR COMPLETE FEE SCHEDULE
- r
WORKERS'COMPENSF.TION DECLARATION 76P9636 1280) , APPLICATION.. FOR ELECTRICAL,PERMIT
76- 6
I hereby affirm that h have a certificatesof'consent to self COUNTY,OF LOS ANGELES ! � BUILDING AND SAFETY
insure, or a certificate of Workers Compensation Insurance,oil
a certified copy thereof(Sec. 380Q Vali.C:)
' FOR APPLICANT TO FILL IN JOB _
Policy No. Comp _ O
I any Ne'w Residential Bldgs.&Pools EACH , NO. FEE _ ADDRESS , I
Certified copy'is hereby furnished. _ 1 &2-Family;Sq. FL $' $ .LOCALITY
l Multi-family Sq:Ft. — NEAREST r� -
erttfred copy is filed with)the county building inspection - CROSS ST L.✓
department. - Residential Swimming Pools, r OWNER OR
FI RM NAME I O
Date-/ �L Applicant c Outlets Rec:I Light�Sw.g i1 %lj. MAIL )
I -First,20 ADDRESS
CERTIFICATE OF EXEM PTION,FROM WORKERS' Total No. Additional CITY _ Tel No.
COMPENSATION INSURANCE
PLAN CHECK - O
(This section need'not be completed if the work involved APPLICANT U
by she permit is for one bandied -dollars (5100) or less.) Lighting Fixtures First 20 ADDRESS
.. Additional2
10
I certify that in the performance of tnefw�ork for which this Total No. •y CITY, Tel No:
Fixed'Appliances Not Over 1.HP
permit is issued, I shall not employ any'person.m any'nianner t PERMIT U
so as to become subject to the-Workers! Compensation Laws. Range_.Heater—D.W. _ z APPLICANT , '� � d
. Oven _ Dryer_a.m. ADDRESS3 'A - Z
Date 'Applicant
,i Top — FAU —.W.H_—
-
Hood. Fan --Other_ CITY _L Tel
NOTICE TO APPLICANT: If, after making this Certificate of Disp. _ Room Air Cond._• LICE NS E.OR a
Exemption, you should become subject to the Workers' - ). REG'. NUMBER " Z Class .
Compensation provisions of the Laboi Code, you must forth Power Apparatus&'Large Appliances DISTRICT PRO ES BY
with comply with such provisions on ttiis permit
deemed revoked. shall be '-Size& Type HP, KW,KVA;or KVAR
,
to
Over
Incl. FINAL
Over 1..to 10 Incl. -
DATE'
LICENSED CONTRACTORS DECLARATION - `S13 VALIDATION
: ,• I Over 10 to 50 Incl. -
I hereby affirm that I am licensed under provisions of Chapter / Over 50 to 100 Inc.
FINAL
V'QL l -
9 (commencing with Section 7000) of Division 3 of the.Busi- Over 100 -
ness and Professions.Code,.and my license is in full force and r
effect. - Services
License Number I,ic..Class - t' 0-200 Amp. Under 600V
201-1000 Amp. Under 6001V
Contractor' Date: Over 1000 Amp.or'Over 600 V _
' HOME OWNER-BUILDER DECLARATION
- Temp. Power Pole&Appurtenances
Sign with One Branch Circuit -
I•hereby affirm that I, am exempt from the Contractor's. additional Sign,Branch.Circuits - -'
License Law for the following reason (Section 7031.5, Bust
ness and Professions Code): -.
Misc.-.Conduits&.Conductors
.I, as owner of the property, wi]Vdo the-work and the ' 'Other (See Complete<Fee'Schedule)—
structure is not 'intended or offered for safe (Section
7044 Business and Professions Cade). ! _
CONSTRUCTION LENDING AGENCY 36 1,.2 A s
I hereby affirm that there is a construction lending agency -
for the "performance of the work for which this permit is PERMITTEE (Sub-Total)- , # e'e:0.0 e 2
issued (Sec 3097;Civ.
Lender's Name -�-- PLAN CHECKING FEE (One-Fourth Permit Fee) - - 2 e;a 24, 1.0
,Lender's Address -{�-- - PERMIT.ISSUING FEE • I - e.o'e 2 it 11001
I certify(that I have read this application and state that the I TOTALFEE . , - Old,05-81_
above information is correct. I agree'to comply with all County - .I
ordinances and State laws regulating Electrical wiring, and-
hereby authorize representatives of this County to enter uponthe abovvee-mentioned property forinspection purposes.
SEE REVERSE FOR.EX PLANATORY LANGUAGES '
'Signature of Permee Date