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HomeMy Public PortalAbout9173 FORTSON DR_Electrical__ 76A663—t'E&06101/72 APPLICA I-ON OR ELEC RICAL PERMIT COUNTY'OF LOS ANGELES DEPARTMENT OF COUNTY ENGINEER F q BUILDING AND SAFETY DIVISION SS L ITY EST FOR APPLICANT TO FILL IN CROSS ST <, OUTLETS NO EACH FEE OWNER OR FIRM NAME RECEPT.0 s MAIL FIRST 2025 DO ADDRESS �7-- LIGHT TOTAL OVER 20 / CITY TEL. N0. 2 32(b SWITCH 10 ( O PLAN CHECK LIGHTING TOTAL F 25'FIRST 20 APPLICANT � OVER 20 ADDRESS FIXTURES 10 ' RESIDENTIAL APPLIANCES CITY TEL. NO. ' PERMIT RANGE DRYER_j_WTR. HTR. APPLICANT tf r STA. COOK DISP. F.A.U. ADDRESS SPACE HTR. AIR COND - CITY © TEL. NO. - CLOTHES WASH: LICENSE OR DISHWASH. REG. NUMBER CLASS. FAN OTHER 100 /S 1 HEHEBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION (f AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY MOTORS, TRANSFORMERS RATING WITH ALL -COUNTY ORDINANCES AND STATE LAWS REGULATING IND. HEATERS, ETC HP. KW. KVA ELECTRICAL WIRING SIZE & TYPE OVER TO I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED ANO/OR 0 — 1 100 LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF CALIFORNIA ORTHAI I AM THE LEGAL OWNER OF THE ABOVE r 1 — 1O 300 DESCRII'ED RESIDENTIAL PROPERTY a— C3 PERMITEE V 10 - 50 500 SIGNATURE����. LL O 50 - 100 1000 DISTRICT N0. PROC SED BY 11.- DISTRICT 100 - 500 1500 or 8 N Z_ SIGN, GAS SIGN AND ONE CIRCUIT_' 5.00 APPROVALS DATE INSPECT SSIGNATURE TUBE, OR MARQUEE ADDITIONAL CIRCUITS - 100 TEMP. POWER POLE � SERVICENOTOVER 600VOLTS OR200AMP 300 UNDERSLAB WORK I SERVI CEOVER 600 VOLTS OR 200 AMP 1000 ROUGH CONDUIT TEMP SERVICE, POLE, &APPURTENANCES 500 WIRING TEMP LIGHT OR RECEPT. SYSTEM 300 FIXTURES �/� -ItY ' Y 1 POWER AUTHORIZED UTILITY CO. NOTIFIED 7—/7—`//+V • FINAL 17`;/ --7L¢ PERMIT FEE (SUB TOTAL) NOTES: PLAN CHECK FEE PERMIT ISSUING FEE 300 O TOTAL FEE PLAN CHECK VALIDATION CK M 0 jAS' PH ERMIT VALIDATION CK M 0 CASH s 3P 2 .0 1 8.8 5 �yti SEE BACK OF APPLICATION FOR COMPLETE SCHEDULE , WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12-91) 76A663 APPLICATION FOR ELECTRICAL PERMIT IJ I hereby affirm that I have a certificate of consent to self insure, or a certificate of Worker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV. copy thereof(Sec.3800 Lab.,C.) Policy No Company - FOR APPLICANT TO FILL IN JOB ADDRESS /7� ❑ Certified�copy is he furnished. New Residential Bldgs &Pools NO EACH FEE - .. _ LOCALITY L Certified copy is filed with the county building Inspection 1&2.Family,Sq.Ft $ $ NEAREST department Multi-family Sq. Ft. CROSS ST Residential Swimming Pools ASSESSOR Date Applicant MAP BOOK � PAGE4 PARCEL CERTIFICATE OF EXEMPTION FROM WORKERS OWNER OR COMPENSATION INSURANCE Outlets Rec._Light Sw FIPM NAME ��, � (This section need not be completed First 20 MAIL the work involved by the Total No. Additional ADDRESS �- permit is for one hundred dollars($100)or less.) I certify that in the performance of the work-for which this permit CITY 7L Tel No is issued, I shall not employ any person iA'any manner so as t0 PLAN CHECK become subject to the Workers' Compensation Laws- Lighting Fixtures First 20 APPLICANT Total No. Additional - .ADDRESS Date Applicant RESIDENTIAL APPLIANCES NOT OVER 3 HP. NOTICE TO APPLICANT If, after making this Certificate of CITY Tel No Exemption,you,should become subject to the Workers'Compensation OTHER APPLIANCES NOT OVER 3 HP. provisions of the Labor Code, you must forthwith comply with suchRMIT provisions or this permit shall be deemed revoked Power Apparatus&Large Appliances APPLICANT jL6 4ACCLA(,44 LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR /' ADDRESS �UI� O fJ 1` I hereby affirm that I am licensed under provisions of Chapter 9 44, (commencing with Section 7000) of Division 3 of the Business and Over 3 to 10 Incl CITY�� l Tel No� (� Professions Code, and my license is in full force and effect Over 10 to 50 Incl } LICENSE OR Class Over 50 to 100 InCI REG NUMBER Q. License Number Lic Class Over 100 DISTRICT NO. PR SED BY Q r7 Services,Swbd,MCC&Panelbcards � Contractor Date 0-399 Amp. Under 600 V FINAL DATE Q ❑ 1 am exempt'under Sec 400-1000 Amp Under 600 V / Over 1000 Amp or Over 600 V FINAL VALIDATION LU B.&P.0 for this reason BRANCH CIRCUIT FEES BY y a Date 15A,or 20A, 120V,Lighting or Recept. / Z_ 1 To 10 Branch Circuits Signature 11 To 40 Branch Circuits ❑ 41 Or More Branch CIrcults Exemption for Reg.Maint.Elect. 15A,20A,208V To 277V Lighting Br Circuits SINGLE FAMILY Temp'Power Pole&Appurtenances HOME OWNER-BUILDER DECLARATION n with One Branch Circuit I hereby affirm that I am exempt from the Contractor's License Law Sign ()�(` .4 for the following reason (Section 7031 5, Business and Professions Additional Sign Branch Circuits , — Code) 330 �`t o 4•r ❑ EI1I, as owner of the property, will do the work and the structure Misc.Conduits&Conductors j 1T �lS is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) r AL 34 - 43 and Professions Code). �!f 7 CONSTRUCTION LENDING AGENCY HECK 34043l�l� I hereby affirm that there is a construction lending agency for the CHANGE eDO performance of the work for which this permit is issued,(Sec. 3097, PERMIT FEE (Sub-Total) Civ C.) PLAN CHECKING FEE q 4 t 11 Lender's Name 13000—Z.,01 1 / -'-,X PERMIT ISSUING FEE 75 �'!' 3:5 7 Lender's Address I certify that I have read this application and under penalty of.purjury state TOTAL FEE that the above 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-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE SI RE OF PERMIT DATE