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Home My Public Portal About10504 KEY WEST ST_Electrical__ 7B A663 5SA 54 1APPLICATION FOR ELECTRIC PERMIT DA 2 DIVISION OF BUILDING AND SAFETY Department of County Engineer County of Los Angeles BUILDING WM. J. FOX, COUNTY ENGINEER ADDRESS CASSATT D GRIFFIN, SUP T OF BUILDING ...mow FOR APPLICANT TO FILL IN LOCALITY f t PERMIT FEES NEAREST 1 CROSS ST NUMBER EACH FEE LIGHT OUTLETS OWNER - RECEPTACLES MAIL ADDRESS WALL SWITCHES TOTAL OUTLETS 5E S CITY TEL NO ELEC RANGES 25 ELECTRICIAN ELEC HEATERS 25 ADDRESS KW SEA CITY TEL NO FIXTURES t 5 LICENSE NO NUMBER OF LIGHT CIRCUITS *'c �rtd LE CIRCUITS DISTRICT NO GROUP ZONE READY FOR INSPECTION NUMBER OF RECEPTAC +� MOTORS NUMBER HORSEPOWER FEE INSPECTION RECORD NEW MVD HP OVER INC EACH y _ LESS $ 25 y Lf R 12 2 50 2 5 Too 5 15 1 50 15 50 2 50 50 200 500 MISC - NO SIGNS NO TRANS NO SIGNS NO LAMPS FOR EACH PERMIT WIRING $100 _L Q FIXTURES $100 SUPPLEMENTARY 50- APPROVALS TOTAL FEE $ S DATE INSPECTOR'S SIGNATURE 1 HEREBY ACKNOWLEDGE THAT I 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 ELECTRICAL WIRING 1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR FIXTURES LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF CALIFORNIA OR THAT 1 AM Ty,E LEGAL- OWNER OF THE ABOVE POWER DESCRIBED RESIDROP Y- SIGNATURE UTILITY CO-NOTIFIED OF PERMITTEEEEEEE��'VVV'VVV////// r FINAL' CROP WILLIAM J. FOX, COUNTY-ENGINEER VALID �1+ 6 2 t aM► 21 2 1, .2 5 � EIY DEPUTY / WORKER'S COMPENSATION DECLARATION 9 DPW(12 91) APPLICATION FOR ELECTRICAL PERMIT 76A66 I hereby affirm that I have a certificate of consent to self Insure, 76A663 or a certificate of Worker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT.QF PUBLIC WORKS BUILDING AND SAFETY DIV copy thereof(Sec 3800 Lab C) • Policy No FOR APPLICANT TO FILL IN / �/�F•� Company JOB ADDRESS A C E-1- Certified copy is hereby furnished New Residential Bldgs &Pools NO EACH * FEE LOCALITY ❑, Certified co is filed with the count building inspection 1 &2-Family,Sq Ft — $ $ ' PY Y 9 P NEAREST 144-1department , I Multi-family Sq Ft CROSS ST Date Applicant Residential Swimming Pools ASSESSOR MAP PAGE IPARCEL CERTIFICATE OF EXEMPTION FROM WORKERS', OWNER OR r COMPENSATION INSURANCE Outlets Rec _Light SW FIRM NAME .54/� tt 2c First 20 ,MAIL '�9'y0� /BEY (This section"rieed not be completed if the work Involved by the Total No Additional ADDRESS 0JVy ` lW�'s7 permit Is for one hundred dollars($100)or less) 1 certify that In the performance of the work for which this permit CITY pCM�' r Tel No ��/i/ 7 is issued, I shall not employ any person in any manner so as to PLAN CHECK f� become subject to the Workers'Compensaatt�/Q?LLaawwsss Lighting Fixtures First 20 APPLICANT ��'c'Ll ��r.�,e•c, Total No Additional -q, 3 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 APPLJANCES NOT OVER 3 HP �,' � //�� provisions of the Labor Code, you must forthwith comply with such power Apparatus&Large Appliances 1,`APPPERLICANT L,;�L /d. �~.tJ[1Cc IT provisions or this per shall be deemed revoked LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS Cl" 5/y fli, I hereby''-affirm that I'am licensed under provisions of Chapter 9 Over 3 to 10 Ind � (commencing with Section 7000) of Division 3 of the Business and CITY 6LE/V0p440-4 Tel No 331S__10,3 Professions Code, and my license is in full force and effect Over 10 to 50 Incl >_LICENSE OR % �'? Class --`� Over 50 to 100 IndREG NUMBER ,7a. License Number LIC CI8S5 Over 100 DISTRICT NO P SSED BY O ` - -` -�7 /' Services,S d MC Pagelbo/3r5 U 41 FINAL Contractor C,4QL r'°{ /�/1J t� Date 9 r l �/" - 399 A Undeeerr 0600 D DATE 0 ❑ - 400- 00 Amp Under 600 V 121�_ f7 I am exempt under Sec VALIDATION LU r 1 00 Amp or Over 600 V FINAL - Ll.l B&P C for this reasonCH CIRCUIT FEES BY U) Date xp 15A,or 20A, 120V,Lighting or Recept Z_ - 1 To 10 Branch Circuits Signature 11 To 40 Branch Circuits ❑ 41 Or More Branch Circuits Exemption for Reg Maint Elect 15A,20A,208V To 2T7V Lighting Br Circuds i SINGLE FAMILY Temp Power Pole&Appurtenances HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit �G� t av I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031 5,,Business and Professions Additional Sign Branch Circuits Code) J 01 ��l�I,jl S ❑ I, as owner of the property,will do the work and the structure Mlsc Conduits&Conductors 1 I j`M'_, Is not Intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) TOTAL �00 �� and Professions Code) t HE l� - CONSTRUCTION LENDING AGENCY t-HECr �'C I I 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) Civ C) PLAN CHECKING FEE Lender's Name (O v i1 i L 1 AN 0 17 ' Lender's Address PERMIT ISSUING FEE / I certify that I have read this application and under penalty of purjury state TOTAL FEE (J � that the above information is correct I agree to comply with all County ordinances and Slate 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 SIGNATURE OF PERMITTEE DATE