HomeMy Public PortalAbout4904 ENCINITA AVE_Electrical__ DBS 5A 12 54 Y A LICATION FOR ELECTRIC PERMIT
1
DBS 9A 1
DIVISION OF BUILDING AND SAFETY
Deportment of County Engineer
County of Los Angeles BUILDING
WM J FOX, COUNTY ENGINEER ADDRESS 4904 Encinita
r CASSATT D GRIFFIN, SUPT OF BUILDING
LOCALITY San Gabriel
FOR APPLICANT TO FILL IN
_
PERMIT FEES NEAREST
FEE CROSS ST
NUMBER EACH OWNER Jack Shipman
LIGHT OUTLETS 11
RECEPTACLES _ MAIL
ADDRESS
WALL SWITCHES �
TOTAL OUTLETS 50 S CITY - TEL NO
ELEC RANGES 25 ELECTRICIANiGoEs pamCorbin
ELEC HEATERS 25 _ ADDRESS 1600 So. Curtis
KW EA CITY Alhambra TEL NW
u 335-2-6-
FIXTURES 5 LICENSE NO llag4k C10
NUMBER OF LIGHT CIRCUITS DISTRICT NO GROUP ZONE I READY FOR INSPECTION'
NUMBER OF RECEPTACLE CIRCUITS
MOTORS D°n
NUMBER HORSEPOWER FEE INSPECTION RECORD
NEW MVD' HP OVER INC EACH
2 112&LESS $ 25 .50
lf2 2 50
2 5 1 00
5 15 1 50
15 50 250
50 1 200 500
MISC
t
NO SIGNS NO TRANS
NO SIGNS NO LAMPS
FOR EACH PERMIT
WIRING $1 00
FIXTURES $100 2® 00 ,
SUPPLEMENTARY 50
APPROVALS
TOTAL FEE -1- 4- 185 DATE INSPECTOR S SIGNATURE
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CONDUIT
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING WIRING lS S S 1C
ELECTRICAL WIRING
IHEREBY CERTIFY THAT I AM P Y GIST AND/OR FIXTURES
LICENSED AS REQUIRED BY LOS ES COUN Y STATE OF POWER A A
CALIFORNIA OR THAT 1 AM OWN THE ABOVE
DESCRIBED RESIDENTIAL �
SIGNATURE UTI LITY CO NOTIFIED ZZ, gS
OF PERM ITTE FINAL QJ
WILLIAM J FOX, COUNTY ENGINEER VALIDAT 7 s 'FM28 2 4. rJ to
BY
O DEPUTY
r _
WORKERS COMPENSATION DECLARATION 63 10/81 APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I hav; CE 8 a certificate of consent to self CE 806G �j
insure, or a certificate of Workers' Compensation Insurance, COUNTY,OF LOS ANGELES BUILDING AND SAFETY IUI
or a certified copy thereof (Sec 38000 LLobb� i
PolicyNowa Com on r - ', ruild FOR APPLICANT TO FILL IN JOB
❑ Certified copy is he�ebyfurnished New Residential Bldgs & Pools EACH NO FEE ADDRESS
Certified copy is filed with the county building inspec- 1 & 2-Family, Sq Ft $ — $ LOCALITY
o�partment Multi-family Sq Ft — NEARESTCROSSST
Residential Swimming Pools OWNER OR
DaApplicant FIRM NAME
CERTIFICATE OF EXEMPTION FROM RKERS' Outlets Rec—/J—(Light 4 Sw MAIL
COMPENSATION INSURANCE First 20 ADDRESS D
(This section need not be completed of the work involved by Total No Additional CITY �� C Tel No
the permit is for one hundred dollars ($100)or less )
that in the performance of the work for which this PLAN CHECK
I certify p APPLICANT
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
Ran e_ Heater_D W APPLICANT
Exemption; you should become subject to the Workers' 9 � a
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 revokedCITY �T e ����Tel No 6 s�
LICENSED CONTRACTORS DECLARATION Hood _ Fan _Other_
LICENSE ORtj (I
I hereby affirm that I am licensed under provisions of Chapter 9 ' Disp _ Room Air Canal J ¢ ass
REG NUMBER CI-7s
(commencing with Section 7000) of Division 3 of the Business Power Apparatus & Large Appliances DISTRICT NO , P SED BY D-
and Professions Code,and my license is in full force an effect /, a U
'/ Size & Type HP, KW, KVA, or KVAR r'/'
License Number 77�e Lic Class Up to 1 Incl FINAL �
Over 1 to 10 Incl DATE y
Contractor Date (f VALIDATION
F-1 Over 10 to 50 Incl FINAL �r/� 1.1
0-
I am exempt under Sec Over 50 to 100 Inc BY U)
B&P C for this reason Over 100 Z
Date Services, Swbd , MCC& Panelboards
0 -200 Amp Under 600 V
Signature 201 - 1000 Amp Under 600 V _ -
❑ Over 1000 Amp or Over 600 V
Exemption for Reg Maint Eject
SINGLE FAMILY Temp Power Pole & Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License Additional Sign Branch Circuits ;2 5 8A 8 A
Law for the following reason (Section 7031 5,'Business and
Professions Code) # o 0- o ° 2
❑ 1, as owner of the property, will do the work and the Misc Conduits &Conductors °'O 2 5,5 0
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ ,
7044, Business and Professions Code) ° ° ° 2 5 5,0 c=i
CONSTRUCTION LENDING AGENCY _ Q 1. 1 3 x 8 6
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)
(Sec 3097, Civ C )
PLAN,CHECKING FEE
Lender's Name
PERMIT ISSUING FEE
Lender's Address 42
j certify that I have read this application an state that the TOTAL FEE
above information is correct I agree to comply with all County
ordinances and State jaws regulating Electrical wiring, and
hereby authors a representatives of this County to enter upon
the above-mebonZdpperry for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
ignature o Pe it a Date