HomeMy Public PortalAbout4900 CLOVERLY AVE_Electrical__ 76^663-CE8069-54 APPLICATION FOR ELECTRICAL PERMIT
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER BUILDING C
BUILDING AND SAFETY DIVISION ADDRESS t1D -t, vh,P�- 4via
JOHN A LAMBIE, COUNTY ENGINEER �� CITY A�
COLEMAN W JENKINS SUP T OF BUILDING LOCALITY C—M
NEAREST Q WF :;z v
FOR APPLICANT TO FILL IN cRoss ST
RECEPT TOTAL NO EACH FEE
OUTLETS FIRST 20 $20 $ /� /}�J OWNER LL /�i1
LIGHT ` T v v MAIL ,t
(/CJ ADD'l ADDRESS (JO CI-oV�eA- / i/E
SWITCH r OVER 20 1044 w
I L �/L/ LL 4
LIGHTING TO 1 I/�{�q i F7R5T20 /�
CITY TEL NO G
20 ��70CGC
3
FIXTURES 1 f_/1 ADD'L to ELECTRICIAN CU
V� OV R 20
RANGES CLO DRYERS k-WTR HTRS 1 00 ADDRESS
GARB DISP L/ STA COOK CITY TEL NO
DISHWASH AUTO WASH✓ STATE
SPACE HTRS STA APP (yy H P MAX ) 50 LICENSE NO
MOTORS OVER NOT OVER ^.H P DISTRICT NOG P O P E Sf D B
O
O 1 100
1 3 150 INSPECTION REC RD
3 S 200 G.
�CA O
8 15 250 ' V
15 50 300 AM" �
0=
s
so too 500 V
f UJ
SIGNS NO TRANS / H
NO LAMPS Z
SERVICE O 600V NOT OVER 200A ✓ loo
SERVICE O 600V OVER 200 A 2 00
SERVICE OVER 600V 500
MISC
PERMIT ISSUING FEE 1200
SUPPLEMENTARY PERMIT ISSUING FEE 1100
TOTAL FEE $
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION APPROVALS DATE INSPECTOR S SIGNATURE
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CONDUIT
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
ELECTRICAL WIRING WIRING -i-
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR FIXTURES
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF
CALIFORNIA OR THAT I AM THE LEGAL OWUR OFAND INTEND TO
RESIDE IN THE ABOVE SC IBE SIDE I l PROPERTY POWER
SIGNATURE UTILITY CO NOTIFIED
OF PERMITTEE
FINAL A�ai.4l
DATION JOSE H C ROOHAN
CK O CASH SUPERVISING ELELE
CTRICAL ENGINEER
ALo 2 5 1 5 Jury 10 2 D 1 4.42 0
i
V1/ORKERS COM NSATION DECLARATION, 76A663 loiet APPLICATION FOR ELECTRICAL PERMIT
r'• Ier215y affirm tlaat I have a certificate of consent to self CE 8066
insure, or a certificate of Workers Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a s�tifcolp�thereof (Sec 3800, L b C )
Policy o Mgt;
_C0mpany FOR APPLICANT TO FILL IN JOB
❑ -Certified copy is hereby furnished New Residential Bldgs & Pools EACH NO FEE ADDRESS
�❑ I & 2-Family, S Ft $ — $ LOCALITY ,
Certified'copy is'filed with the county building inspec- Y� 9
tion epart ent t Multi family Sq Ft - — NEAREST
I/ t CROSS ST
Date Applicant1�DAI/ -(/ Residential Swimmirig Pools OWNER OR
+ FIRM NAME
ti
�l
CERTIFICATE OF EXEMPTION FROM WORKERS'" Outlets Rec�L ght Sw_ + I ° - MAIL
COMPENSATION INSURANCE First 20 ADDRESS (c��
(This'section need not be completed if the work involved by r CITY I No
the permit is for one hundred dollars ($100)or less ) ' Total No Additional
Pr
PLAN CHECK
I certify that in the performance of the work for which this _ APPLICANT r
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
Total No Additional - CITY Tel No
Date Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT If, after making this Certificate of I APPLICANT �I
Exemption, you should become `suBject I to the Workers% Range— Heater,_D W —
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— r CI e
LICENSED CONTRACTORS DECLARATION LICENSE OR
I hereby affirm that I am licensed under provisions of Chapter 9 Disp Room Air Cond REG NUMBER - Class
(commencing with Section 7000) of Division 3 of the Business DISTRICT NO PROCES D Y
and Professions Code and my license is in full force a>n ffect Power Apparatus & Large Appliances _ _(�
Size &Type HP KW KVA, or KVAR f U Q
Licei nse Number / L,c Class Up to 1 Incl FINAL �_ U
V � � h � DATE VA ATION Q
+ . Over 1 to 10 Incl —�
Contractotel / Date Over 10 to 50 Incl
FINAe U,
❑ I am exempt under SecOver 50 to 100 Inc BYLU
B&P C for this reason Over 100 H
Services, Swbd MCC & Panelboards
Date 0 - 200 Amp Under 600 V
Signature 201 - 1000 Amp Under-600 V j
❑ Over 1000 Amp or Over 600 V 6 1 0 3 A
Exemption for Reg Maint Elect
SINGLE FAMILY Temp Power Pole&Appurtenances # e o 0 0 0 2
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor s License e - 120
Law for the following reason (Section 7031 5, Business and Additional Sign Branch Circuits _
Professions Code) 0 0 0912 010 `
❑ I as owner of the property will do the work and the Msec Conduits 8 Conductors '
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ , y 2,1T2''8 6
7044 Business and Professions Code)
CONSTRUCTION LENDING AGENCY - -
I hereby affirm that there is a construction lending agency fors _
the performance of the work for which this permit is issued PERMIT FEE+ t (Sub-Total) - -
(Sec 3097, Civ C ) ,
PLAN CHECKING FEEM - -
Lender s Name '
PERMIT ISSUING FEE
Lenders Address
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
ordinances and State laws regulating Electrical wiring and 1
hereby uthorize representatives of this County To enter u on f
thea e- honed propati or nhis County
pus ones
SEE REVERSE FOR EXPLANATORY LANGUAGE
So natur o P ttee ate I a