HomeMy Public PortalAbout5753 GOLDEN WEST AVE_Electrical__ .76A663C- CE606B 12/75 APPLICATION FOR ELECTRICAL PERMIT,
BUILDING AND SAFETY DIVISION
FOR APPLICANT TO PILL IN ,JOB
F&2Fma;IySq
ntial Bldgs. &,Pools
EACH NO FEE' ADDRESS
aily Sq Ft $ — $ LOCALITY LC 112-Yily Sq. Ft — NEAREST .al Swimming Pools CROSSST.OWNER OR
FIRM NAME .6-(m(ht, Switch& Receptacle MAI LADDRESS Gal CITY Tel No Q
PLAN CHECK
APPLICANT
Lighting Fixtures _
First 20 Q ADDRESS
Additional
CITY Tel No
PERMIT
Fixe �G� T
d Appliances Not Over 1 HP APPLICANT
Range_ Heater D W
ADDRESS
Oven Dryer W M :L
Top FAU W H CIT Tel No
Hood Fan LICENSE OR a
REG NUMBER Class
Disp. A C.
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
ANO STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY Q
Power Apparatus& Large Appliances WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
ELECTRICAL WIRING r.>
Size&Type HP, KW, KVA,or KVAR
lUp to 1 Incl 1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED ANO/OR Z
Over 1 to 10 Incl /S-o LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE
Over 10 to 50 Incl. DESCRIBED RESIDENTIAL PROPERTY
Over 50 to 100 Incl PERMITEE
Over 100 SIGNATURE
DISTRICT NO P SSED
Services - C�
0-200 Amp Under 600 V i� �� CJ
201 -1000 Amp. Under 600 V APPROVALS, DA� INSPECTOR'S
TRE
Over 1000 Amp or Over 600 V
TEMP POWER POLE
Temp. Power Pole,&Appurtenances UNDERSLAB WORK
Sign with One Branch Circuit
ROUGH CONDUIT
Additional Sign Branch Circuits
(Other) WIRING
FIXTURES
P WER AUTHORIZED
PERMIT FEE UTILITY CO NOTIFIED
PLAN CHECKING FEE (One-Fourth Permit Fee) FINAL
PERMIT ISSUING FEE
NOTES:
TOTAL FEE 9�
PLAN CHECK VALIDATION CK M O CASHPERMIT VALIDA ON CK M O CASH'
7 T;5,r,T'EC+ 1-5 2 U 5 C�.� V ��✓3
j WORKERS'COMPENSATION DECLAP4TION ! CEA8663 o6G 10/81 APPLICATION FOR ELECTRICAL PERMIT
ti
I•herMy"affirm that I have a certificate of consent to self insure,
or a certificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING' AND SAFETY
,n,copy,ther'eoli(Sec 3800,Lab C)
Poticy No ' Company FOR APPLICANT TO FILL IN JOB ,Z'^��� !/ _ , ,,Q�
Certified copy is herebyfurnished EACH NO FEE ADDRESS `f fa(vv •�(/
New Residential Bldgs & Pools
❑ 1 & 2-Family, Sq Ft $ — $ LOCALITY Gf
Certified copy is filed with the county building inspection
department Multi-family Sq Ft — NEAREST
CROSS ST
Date Applicant Residential Swimming Pools OWNER OR ��11 `�� 1�
FIRM,NAME 05 C� R11 40.b G V`C
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets Rec Light gw MAIL
COMPENSATION INSURANCE D 3 ADDRESS 3>40W
(This section need not be completed If the work Involved by the First 20
Total No Additional CITY Tel N-11
permit Is for one hundred dollars($100)or less)
I certify that in the performance of the work for which this permit PLAN CHECK
APPLICANT
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
)7_"L� Total No Additional CITY Tel No
Date /0—
O,Applic t
NOTICE TO. APPLICANT If, after making,this ertific of Fixed Appliances Not Over 1 HP PERMIT
Exemption,you should become subject to the Workers'Compensation Range_ Heater_ DW _ APPLICANT
provisions of the Labor Code, you must forthwith comply with such Oven _ Dryer _ W M _ ADDRESS '
provisions or this permit shall be deemed revoked ' I Top — FAU _ WH
CITY Tel No
• LICENSED CONTRACTORS DECLARATION Hood — Fan Other_
I hereby affirm that I am licensed under provisions of Chapter 9 LICENSE OR
DiSp Room Air COnd REG NUMBER Class
(commencing with Section 7000) of Division 3 of the Business and
Professions Code,and my license is in full force and effect DISTRICT NO PROCESSED
Power Apparatus& Large Appliances �� n a
Size& Type HP,KW,KVA,or KVARv�"
License Number- Lic Class Up to 1 Incl FINAL U
Over 1 to 10 Incl DATE ZD
Contractor Date q/
VALIDATION O'
❑ Over 10 to 50 Incl FINAL
I am exempt under Sec Over 50 to 100 Inc BY W
B&P C for this reason Over 100 N
Services, Swbd,MCC & Panelboards ® 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 Maint Elect
- 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 Law A4�,t•T,s
for the following reason(Section 7031 5, Business and Professions Additional Sign Branch Circuits
Code) 33137 29.20Misc Conduits & Conductors 1 ITEM
I,as owner of the property,will do the work and the structure S
Nr is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule)
and Professions Code) lot- TOTAL 29 - 20
CONSTRUCTION LENDING AGENCY CHECK 2,9")(1
1 hereby affirm that there is a construction lending agency for the
performance of the work for which this permit is issued(Sec 3097, PERMIT FEE (Sub-Total) CHANGE .00
Civ C)
PLAN CHECKING FEE ftn
Lender's Name 0000-0001 10�l8�9li
PERMIT ISSUING FEE _
Lender's Address 3677 1 AM 7°231
1 certify that I have read this application and state that the above TOTAL FEE
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
411ghnature�'�of
or inspection p poses ^ SEE REVERSE FOR EXPLANATORY LANGUAGE
���,� ✓��
Permit Date