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HomeMy Public PortalAbout9515 LA ROSA DR_Electrical__ DBS SA�2�5¢yM/g SSE�TE 7-47 DEPAR'T'MENT OF BUILDING, AND SAFETY MPUCAT10N FOR PETOUT COUNTY OF LOS ANGELES ELECTRIU WWI. . FOX CHIEF ENGINE%R `µ NAME " DISTRICT-NO. GROUP ZONE PERMIT NO. a - ADDRESS FU,, CITY TEL.NO. RECEIVED BY READY FOR DATE�iSSUED FIRST INSPECTION N 7 CERT.-Lf TqeEXPIRES CA APPLICANT FILL IN 11EAVILY OtITLINED PORTION ONLY JOB DESCREMON OF WORK ADDRESS .o PLUMBER OF OUTLETS ON CIRCUITS LOCALITY LOCATION BY ROOMS v y NEAREST ' LIGHT OUTLETS JSW. PLUGS FWT CROSS ST. CIRCUIT A .13 -r-_=®d E F G JH It NAME w s 7 lla ADDREss CITY WP t=* STEL.N0. IAM THE LEGAL POSSESSCQR OF THE ABOVE LOS G ANELES COUNTY CERTIFICATE OF QUALIFICATION.. ELECTRICIAN. H AM THE LEGAL OWNER OF THE PROPERTY DESCRIBED ABOVE OWNER. 9 CORRECTIONS J Q I Z L7 (Y D TOTAL NO. OF OUTLETS (` $ APPROVALS Li I NO. OF FIXTURES v $ �Cf�7 DATE INSPECTOR'S NAME NO. OF MOTORS H.P. $ CONDUIT NO. OF SIGNS TRANS. $ WIRING NO. OF RANGES OR HEATERS $ FIXTURES P4ISCELL NEOU3 $ _POWER PERMIT FEE $ YCO.NOTIFIED �J TO AL FEE q: IFLINAL DBS S-A 12-44 DEPARTMENT O 'BUILDING AND SAFETY APPLICATION FOR PERNIIT F COUNTY OF LOS ANGELES ELECTRIC WM. J. FOXCHIEF ENGINEER zDISTRICT NO. GROUP ZONE PERMIT NO. Q NAM 1 :a < U ADDRESS_ s /_y U CITY IL ° TEL.NO. // 9a® RECEIVED BY READY FOR DATE ISSUED J COUNTY /p �* FIRST INSPECTION I+I CERT.NO. " EXPIRESSZi�'� '✓� r�� / APPLICANT FILL HEAVILY OUTLINED PORTION ONLY DESCRIPTION OF WORD DDRESS:O/W y NUMBER OF OUTLETS ON CIRCUITS LOCALITY � c LOCATION BY ROOMS NEAREST LIGHT OUTLETS lsw. PLUGS I FIXT CROSS ST. CIRCUIT A► B C D E F G H w NAM Z MAIL 3 ADDRESS O CITY TEL.NO. 1 AM THE LEGAL POS �F THE ABOVE LOS ANGELE COUNTY CER C F QUALIFI TION.. ELECTRICIAN. 1 AM THE 1LEGAL OWNER OF THE PROPERTY DESCRIBED ABOVE OWNER. CORRECTIONS J -- Q Z_ P !Y O TOTAL NO. OF OUTLETS V $ S' APPROVALS 1 NO. OF FIXTURES $ DATE INSPECTOR'S NAME 6 NO. OF MOTORS H.P. $ CONDUIT Al e2 NO. OF SIGNS TRANS. $ WIRING NO. OF RANGES OR HEATERS $ FIXTURES MISCELLANEOUS $ POWER PERMIT FEE iI _�= $ UTILITY CO.NOTIFIED 9-49,7- T OTAL FEE S FINAL WORKERS'COMPENSATION DECLARATION CE 806G (2-80) APPLICATION FOR ELECTRICAL PERMIT I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY insure, or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec. 3800,Lab. C.) JOB Policy No. Company FOR APPLICANT TO EACH FILL N NO. FEE ADDRESS ` New Residential Bldgs.&Pools 9J /� D Certified copy is hereby furnished. 1 &2-Family,Sq. Ft. $ -' $ LOCALITY ��pp Multi-family Sq. Ft. — NEAREST Certified copy is filed with the county building inspection Residential Swimming Pools CROSS ST •j�✓/J, department; OWNER ORr RM NAME 0/t.0- Date Applicant Outlets: Rec.e-Light=Sw. AMAIL DDRESS First 20 CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. Additional CITY Tel No. 'S.. COMPENSATION INSURANCE PLAN CHECK t1 APPLICANT (This section need not-be completed if the work involved V Additional by the permit is for one hundred dollars ($100) or less.) Lighting Fixtures First ADDRESS onal ccO Total No. I certify that in the performance of the work for which this Fixed Appliances Not Over 1 HP CITY Tel No. (- permit is issued, I shall not employ any person in any manner PERMIT / U so as to become subject to the Workers' Compensation Laws. Range_ Heater_D.W. APPLICANT �- ��� �C a C Oven _ Dryer_W.M._ ADDRESSj� �� h4n �- U) Date9 r y Applicant / el iTop _ FAU _W.H.. Hood _ Fan _Other_ CITY T No.��� NOTICE TO APPLICANT: If, after making this Certificate of Disp. —Room Air Cond._ LICENSE OR e� Exemption, you should become subject to the Workers' REG.NUMBERS?4-13 Class D Compensation provisions of the Labor Code, you must forth- Power Apparatus& Large Appliances DISTRICT NO. PROCESSED BY with comply with such provisions or this permit shall be deemed revoked. Size&Type HP,KW, KVA,or KVAR Up to 1 Incl. FINAL Over 1 to 10 Incl. DATE LICENSED CONTRACTORS DECLARATION VALIDATION Over 10 to 50 Incl. I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. FINAL BY 9 (commencing with Section 7000) of Division 3 of the Busi- Over 100 ness and Professions Code, and my license is in full force and effect. Services License Numbers- 3 Lic. Class � �/� 0-200 Amo L1ndPr R00 // Gj 201-1000 Amp.Under 600 V \ � `/ Contractor ,(��e� -rr-&JlDate / Over 1000 Amp.or Over 600 V , HOME OWNER-BUILDER DECLARATION Temp. Power Pole&Appurtenances 1 I hereby affirm that I am exempt from the Contractor'sSign with One Branch Circuit r 111 License Law for the following reason (Section 7031.5, Busi- Additional Sign Branch Circuits _4 1 7.5 ness and Professions Code): 9 no 0 0 o 2 Misc.Conduits&Conductors ,o I, as owner of the property, will do the work and the Other (See Complete Fee Schedule)— 2 0 2 7 O O structure is not intended or offered for sale (Section 7044, Business and Professions Code). ° ° 2 5 0'0'C63 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency .09 U -84 for the performance of the work for which'this permit is PERMIT FEE (Sub-Total) issued(Sec. 3097,Civ.C.). Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee) Lender's Address PERMIT ISSUING FEE t?� o N o ^h 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 ° ° o ordinances and State laws regulating Electrical wiring, and = (U N 0 00 herebythorize represent ryes of this County.to enter upon I �1 1 0 -O =Woned ' pro rty for inspect' n purposes. SEE'REVERSE FOR EXPLANATORY LANGUAGE Co O O IN D C O CH Ignature of P rmittee Date 1 WORKERS' COMPENSATION DECLARATION 76A663 DPW 3/87 APPLICATION FOR ELECTRICAL PERMIT I,here,by,Rnffirm that I have a certificate of consent to self CE-eo G insure, or a'certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS or a certified copy thereof (Sec. 3800, Lab. C.) Policy No. Company FOR APPLICANT TO FILL IN JOB FICertified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADDRESS (jy'G7 kIVfi' F-ICertified copy is filed with the county building inspec- 1 & 2-Family, Sq. Ft. $ — $ LOCALITYc tion department. Multi-family Sq. Ft. NEAREST CROSS ST. I•' V Date Applicant Residential Swimming Pools OWNER OR FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec�Light Sw. MAIL ", COMPENSATION INSURANCE Q ADDRESS First 20 (This section need not be completed if the work involved by Total No.-4L— Additional CITY Tel. No. the permit is for one hundred dollars ($100)or less.) PLAN CHECK I certify that in the performance of the work for which this APPLICANT permit is issued, I shall not employ an pTsin any manneso as to become subject to the Work ' �ensa ion Laws. Lighting Fixtures First 20 ADDRESS 3 Additional U37 Date -7" J Applicant2 Total No. CITY Tel. No. Fixed Appliances Not Over 1 HP PERMIT NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers' Range— Heater—D.W. APPLICATION j1V 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_ Q CITY Tel. No. LICENSED CONTRACTORS DECLARATION LICENSE OR I hereby affirm that.)am licensed under provisions of Chapter 9 Disp. — Room Air Cond. — REG. NUMBER Class. (commencing with Section 7000)of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO. PR SED BY >_ and Professions Code,and my license is in full force and effect. a Size &Type HP, KW, KVA, or KVAR �♦ DA 0 License Number Lic. Class Up to 1 Incl. FINAL U Contractor Date Over 1 to 10 Incl. DATE _� �� VALIDATION Cr ❑ Over 10 to 50 Incl. FINAL E' I am exempt under Sec. Over 50 to 100 Inc. BY u B.&P.C. for this reason Over 100 Z D_ Date: Services, Swbd., MCC& Panelboards Z . - 0- 200 Amp. Under 600 V — Signature 201 - 1000 Amp. Under 600 V ❑ - Exemption for Reg. Maint. Elect. Over 1000 Amp. or Over 600 V SINGLE FAMILY Temp. Power Pole &Appurtenances HOME OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Sign with One Branch Circuit t i_:'•. °a Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits -k Prof sions Code): l� as owner of the property, will do the work and the Misc. Conduits&Conductors x =i structure is not intended or offered for sale Section 7044, ther (See�omplete F e Sch ul , s''r;i "=..r '"2 g Business and Professions Code). &Igutl 141 _ CONSTRUCTION LENDING AGENCY j uti `-'HE=F'• I hereby affirm that there is a construction lending agency for E(*P,,•=;— %_ the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) a Q (Sec. 3097, Civ. C.). PLAN CHECKING FEE --_ _•; Lender's Name I il_i_i_i =I i `1 fr ' ° PERMIT ISSUING FEE / �°= Lender's Address ��13 t }'t J r °'" 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 Stat laws regulating Electrical wiring, and he authorize re resentatives of this County to enter upon t above-menytio d property, for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE 12 'Signatur f Per tee Date ©: ^ ' WORKERS' COMPENSATION DECLARATION 2o-ooteDPW aiaz APPLICATION FOR ELECTRICAL PERMIT I hereby-affirm that I have a certificate of consent to self KCE 806G insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS or a certified copy thereof (Sec. 3800, Lab. C.) Policy No. Company FOR APPLICANT TO FILL IN JOB 1 'l ❑Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADDRESS 95 I J �Gf j L}SG1 4l✓II/!i _ ✓>/1 ❑ $ $ LOCALITY Certified copy is filed with the county building inspec- 1 &2-Family, Sq. Ft. — C, tion department. Multi-family Sq. Ft. NEAREST CROSS ST. -Fe vi1 t Date Applicant Residential Swimming Pools OWNER OR FIRM NAME VeC, ^ Cts CERTIFICATE OF EXEMPTION FROM WORKERS' OutMAIL lets: Rec Light Sw._ COMPENSATION INSURANCE First 20 ADDRESS (This section need not be.completed if the work involved by Total No. Additional CITY Tel. No. the'permit is for one hundred dollars ($100)or less.) PLAN CHECK I certify that in the performance of the work for which this APPLICANT permit is issued, I shall notemploy an person in any manner so as to become subject to the Work s'CompensatA�w. Lighting Fixtures First 20 ADDRESS Total No. Additional CITY Tel. No. Date plicant Fixed Appliances Not Over 1 HP PERMIT NOTICE TO APPLICANT: If, after makin his Certificate of APPLICATION p&„k,et-- Exemption, you should become subje t to the Workers' Range— Heater—D.W. — Compensation provisions of the Labor Code, you must forth- Oven.— Dryer W.M.— �j j ADDRESS with comply with such provisions or This permit shall be Top FAU L_W.H. — deemed revoked. Hood — Fan A_Other— CITY Tel. No. LICENSED CONTRACTORS DECLARATION DisLICENSE OR p. — Room Air Cond. REG. NUMBER Class. I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000)of Division 3 of the Business Power Apparatus & Large Appliances DISTRICT NO. R SSED BY >_ and Professions Code,and my license is in full force and effect. �, 0- Size Size&Type HP, KW, KVA, or KVAR �}� -� Q License Number Lic. Class Up to 1 Inc]. 17 FINAL Contractor Date Over 1 to 10 Incl. DATE _JZ VALIDATION W Over 10 to 50 Incl. FINAL O ❑. I am exempt under Sec. Over 50 to 100 Inc. BY U W B.&P.C. for this reason Over 100 d Services, Swbd., MCC& Panelboards to Date: Z �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 w: I hereby affirm that I am exempt from the Contractor's License Sign with One Branch Circuit Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits '-i =_ Professions Code): " I, as owner of the property, will do the work and the Misc. Conduits &Conductors IIII structure is not intended or offered for sale(Section 7044, Other (See Complete Fee Schedule)_ T „._ .s Business and Professions Code). ® :fi!_ CONSTRUCTION LENDING AGENCY - `- 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) �j ,•' ( (Sec. 3097, Civ. C.). PLAN CHECKING FEE Lender's Name PERMIT ISSUING FEE Lender's Address I certify that I have read this application and state that the TOTAL FEE C / above information is correct. I agree to comply with all County orcliD4kces and State laws r uI ting Electrical wiring,•and her authorize represent ve of this County to enter upon the ve-mentione ro y r inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ©$ Signotur f Permittee Date WORKERS' COMPENSATION DECLARATION CE-806 10/81 APPLICATION FOR ELECTRICAL PERMIT •. I hereby affirnn that I have a certificate of consent to self CE-806G insure,,or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY or a certified copy thereof (Sec. 3800, Lob. C.) Policy No. Company FOR APPLICANT TO FILL IN ADDRESS 5, Pol Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE Or 1 ❑ Certified copy is filed with the county building inspec- 1 & 2-Family, Sq. Ft. $ — $ LOCALITY tion department. Multi-family Sq. Ft. NEAREST CROSS SL �� tV►'► '� (`/"L� (/ Date Applicant Residential Swimming Pools OWNER OR CERTIFICATE OF EXEMPTION FROM WORKERS' a MAILMNAME 1/ ✓ e✓tlI/i(i Outlets: Re c Light Sw. COMPENSATION INSURANCE ADDRESS if the work involved b First 20 (This section need not be completedy Total No. Additional CITY f/yidfe L Tel. No. fJ��q.6 the permit is for one hundred dollars (6100)or less.) PLAN CH CK I certify that in the performance of the work for which this APPLICANT permit is issued, I shall not employ any person in any manner so as to become subject to the Wor rs'Compensatio aws. 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 moki s Certificate of APPLICANT ��1 �/ d 0C Exemption, you should become subje 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. — ,r+ L� deemed revoked. Hood _ Fan _Other_ CITY e frn L G Tel. No. —6qd LICENSED CONTRACTORS DECLARATION LICENSE OR I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. REG. NUMBER Class. (commencingwith Section 7000 of Division 3 of the Business ) Power Apparatus& Large Appliarices DISTRICT NQ_ PROC SED BY p, and Professions Code,and my license is in full force and effect. Size &Type HP, KW, KVA, or KVAIR U License Number Lic. Class Up to 1 Incl. FINAL cc Contractor Date Over 1 to 10 Incl. DATE 401, — � V (DATION C) ElOver 10 to 50 Incl. FIN / Lil I am exempt under Sec. Over 50 to 100 Inc. BY / N' All B.&P.C. for this reason Over 100 Z Date: Services, Swbd., MCC & Ponelboards ► 0 -200 Amp. Under 600 V Signature 201 - 1000 Amp. Under 600 V ❑ Exemption for Reg. Maint. Elect. Over 1000 Amp. or Over 600 V ;25 1 1. 1 A SINGLE FAMILY Temp. Power Pole &Appurtenances # o:o o o o 2 HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit �,o o 2 Q O I hereby affirm that I am exempt from the Contractor's License Additional Sign Branch Circuits Law for the following reason (Section 7031.5, Business and 'a 0 0.1 20 0 v Professions Code): I, as owner of thero ert will do the'work and the Misc'. Conduits&Conductors 7 2 3 $6 structure is not intended or offered for sale (Section p y Other (See.Complete Fee Schedule)_ ► 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY 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 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 1rheby auhorize representatives of this County to enter upon above-mentioned roperty for inspection purposes. SEE REVERSE.FOR EXPLANATORY LANGUAGE E ignatur of Permitt e Date WORKERS'COMPENSATION DECLARATION 76-663 10/81 CE-Bose APPLICATION FOR ELECTRICAL PERMIT I hereby tffirm thzi 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 copy thereof(Sec. 3800,Lab. C.) 4 ' r "fl r, Policy No.—s I Company FOR APPLICANT TO FILL IN JOB ❑ Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADDRESS �/ ❑ 1 & 2-Family, Sq. Ft. $ — $ LOCALITY .10 le, Certified copy is filed with the county building inspection department. Multi-family Sq.Ft. — NEAREST CROSS ST. 1 Residential Swimming Pools OWNER OR Date Applicant FIRM NAME / CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:RecLight S— Sw. U /�� MAIL COMPENSATION INSURANCE ADDRESS YE-203Y (This section need not be completed if the work involved by the y Tl No. Additional CITY Tel.No t oFirst 20 permit is for one hundred dollars ($100) or less.) , I certify that in the performance of the ork for which this permit PLAN CHECK is issued, I shall not employ any Pers in any manner so as to APPLICANT become subject to the Workers'Comp sation Laws. Lighting Fixtures First 20 ADDRESS Additional Total No. CITY Tel.No. Date 1 �pplicant t Fixed Appliances Not Over 1 HP NOTIC TO APPLICANT: If, after maki this Certificate of PERMIT Exemption,you should became subject to the Workers'Compensation Range_ Heater_ D.W. APPLICANT 1/V provisions of the Labor Code, you must forthwith comply with such Oven _ Dryer _ W.M. ADDRESS provisions or this permit shall be deemed revoked. Top — FAU _ W.H. LICENSED CONTRACTORS DECLARATION Hood — Fan OtherCITY Tel.No. _ I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. LICENSE OR Class. (commencing with Section 7000) of Division 3 of the Business and REG.NUMBER Professions Code,and my license is in full force and effect. Power Apparatus& Large Appliances DISTRICTNO ! PROCEI 14N a BY Size& Type HP, KW,KVA,or KVAR � License Number Lic.Class Up to 1 Incl. FINAL ^ U Over 1 to 10 Incl. DATED VALIDATION ��/�,�7 Contractor Date v / � � ❑ Over 10 to 50 Incl, FINAL I am exempt under Sec. Over 50 to 100 Inc. BY G B.&P.C.for this reason Over 100 QW„ Services,Swbd.,MCC& Panelboards ® Z Date: 0- 200 Amp.Under 600 V Z 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 DECLARATIONi Sign with One Branch Circuit I hereby affirm that I am exempt from the Contractor's License Law Additional Sign Branch Circuits "PT a for the following reason(Section 7031.5, Business and Professions ft:: °8 Code): - Misc.Conduits &Conductors `301 °'`'C t I as owner of the property,will do the work and the structure is not intended or offered for sale (Section 7044, Business Other (See Complete Fee Schedule) _ 1 ;TEI I: and Professions Code). TOTAL 41E-3 20 CONSTRUCTION LENDING AGENCY -- I hereby affirm that there is a construction lending agency for the CHH("K performance of the work for which this permit is issued(Sec.3097, PERMIT FEE (Sub-Total) {" Civ. C.). CHANGE PLAN CHECKING FEE Lender's Name �_E PERMIT ISSUING FEE .13 bC [1000-0001 7f /5.-_r Lender's Address I certify that I have read this application and state that the above TOTAL FEE 1627 f Art 7°3 information is correct. I agree to comply with all County ordinances UU and State laws regulating Electrical wiring, and hereby authorize re pr entatives of this County o enter upon the above-mentioned pro rty for inspection purpo _ SEE REVERSE FOR EXPLANATORY LANGUAGE gnature of Krmittee Date WORKERS'COhave a-TION DECLARATION CE-806 10/81 APPLICATION FOR ELECTRICAL PERMIT � I her'ekty affirml'that S have a certificate of consent to self CE-806G s'ins2re,rcor a certiificote:,of Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY or a certified copy thereof (Sec. 3800, Lab. C.) Pc�licy No. Company FOR APPLICANT TO FILL IN JOB ADDRESS q,�. Y1 V� Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE Certified copy is filed with the county building inspec- 1 & 2-Family, Sq. Ft. $ — $ LOCALITYTet4l Ie V. tion department. Multi-family Sq. Ft. NEARESTCROSS ST. � Residential Swimming Pools OWNER OR Dates Applicant d FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec�LightSw.� MAIL COMPENSATION INSURANCE i3 .ADDRESS � 1 1,1✓G+ First 20 + •` � ���"v�Y (This section need not be completed if the work involved by Total No. Additional Q CITY'�,�ale 1't\ Tel. No. the permit is for one hundred dollars ($100)or less.) I certifythat in the of the work for which this PLAN CHECK e performance APPLICANT permit is issued, I shall not employ y person in any manner so as to become subject to the Wor rs'Compensat' n Laws. Lighting Fixtures First 20 ADDRESS Total No. Additional f(' CITY Tel. No. Date V Applicant Afilir–le Fixed Appliances Not Over 1 HP PERMIT / NOTICE O APPLICANT: If, after making is Certificate of Exemption, you should become subjec to the Workers' Range HeaterT DAPPLICANT QNtW. aA Compensation provisions of the Labor Code, you must forth- Oven _ Dryer ! W.M. ADDRESS f�yf vz. with comply with such provisions or this permit shall be Top' _ FAU —W.H. — deemed revoked. L Other— CITY Hood Fan Cid Tel. No. ��a31 LICENSED CONTRACTORS DECLARATION T LICENSE OR I hereby affirm that I am licensed under provisions of Chapter 9 Disp. .L Room Air Cond. REG. NUMBER Class. (commencing with Section 7000) of Division 3 of the Business DISTRICT NO. PROCE D BY and Professions Code, and my license is in full force and effect. Power Apparatus& Large Appliances O. Size & Type HP, KW, KVA, or KVAR' Ji U License Number Lic. Class Up to 1 Incl. FINAL 1Y Over 1 to 10 Incl. DATE "'7i� V (DATION Contractor Date !� ~ Over 10 to 50 Incl. FINEl A; I am exempt under Sec. Over 50 to 100 Inc. BY (L' Over 100 Z B.BP.C. for this reason Z_ Date: Services, Swbd., MCC& Panelboards ' 2 6 6 IL-O A 0 - 200 Amp. Under 600 V Signature 201 - 1000 Amp. Under 600 V #�0 0 0 0 0 2 ❑ Over 1000 Amp. or Over 600 V Exemption for Reg. Maint. Elect. �( ° 7 5 O O SINGLE FAMILY Temp. Power Pole & Appurtenances 0 0 0.7 S O 0 C5 HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit I hereby affirm that I am exempt from the Contractor's License Q O 9 $7Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits Professions Code): 1, as owner of the property, will do the work and the Misc. Conduits &Conductors structure is not intended or offered for sale (Section Other (See.Complete Fee Schedule)_ , 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY 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 U Lender's Address /gyJp,p 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 h eby authorize re resentatives of this County to enter upon t above-mentio d property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE G 7 ignat f Permittee I Dat