HomeMy Public PortalAbout6209 LOMA AVE_Electrical__ WORKERS'COMPENSATION DECLARATION 76A663 10/81thAPPLICATION F0
ELECTRICAL PERMIT .
e et4y'tSffirm`that I•have a certificate of consent to self CE-806G �j
insdre, or a certificate of Workers' Corhpensation Insurance, COUNTY OF LOSANGELES BUILDING AND SAFETY 'ul
or a certifi dcopythe'reof (Sec. 3800, Lab. C.)
Policy Nol6 Company 5( TL i=04
FOR APPLICANT TO FILL IN` JOB
0 Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADDRESS Q fU V
-M .Certified copy is filed with th�county ildin inspec- 1 & 2-Family, Sq. Ft. $ — $ LOCALITY ,
tion department. Multi-family Sq. Ft. — NEAREST
Residential Swimming'Pools
CROSS ST.
Dote, ' Applicant ;. ORM NAME,WNER
CERTIFICATE OF EXEMPT N FROM WORKERS' Outlets: Rec L L Light L- Sw. "� MAID
COMPENSATION INSURANCE ADDRESS _
'(This section need not be�completed if th'e work involved by L first 20 CITY �� ) �r
the permit is for one,hundred dollars ($100)or less'.)
Total No. Additional l ` Tel. No.
I certifythat in the performance of'the work for which this PLAN.CHECK
e P APPLICANT
'permit is issued, I shall not employany person in any manner`
so as to become subject to the Workers'Compensation Laws. ' Lighting Fixtures, First 20• ADDRESS
TAdditional
Total No.
—Sr_ CITY Tel. No.
Date Applicant Fixed Appliances Not Over.l HP PERMIT /\' I
NOTICE TO APPLICANT: if, after making this Certificate of APPLICANT. (C L
H CR C-4
Exemption, you should become subject to the Workers' Range_ Heater=D.W. —
Compensation provisions of the Labor Code, youl must forth- Oven _ Dryer W.M.— ADDRESS
with comply with such provisions or this'permit shall be Top — FAU —W.H. — CITY l-_
deemed revoked. L Tel. No.
LICENSED CONTRACTORS DECLARATION Hood — Fan _ Other_ . E GI / �� C i T_ �9
LICENSE,OR
I hereby affirm that l am licensed under provisions of Chapter 9 Disp. Room O Air Cond. REG. NUMBER �L� _ Class. V>
(commencing with Section 7000) of Division 3 of the BusinessDISTRICT NO. r/ PROC EDB 0-
Power Apparatus & Large Appliances d
and Professions Code, and my license is in full force and effect. mit/, U
Size & Type HP„KW, KVA, or KVAR' ✓ v
License Number Lic. Class Up to 1 Incl. FINAL
DATE 0,
Over 1 to 10 Incl, VALIDATION
Contractor Date (r
Over 10 to 50.IncI: FINA /` UJ
ET I exempt under Sec. Over 50 to 100 Inc. .' B
U)Y
B.&P.C. for this reason
Over 100 j
'Services, Swbd., MCC & Ponelboards'. �tv
Date: 0 -200 Amp. Under 600 V U
Signature 201 - 1000 Amp. Under 600 V
aOver 1.000 Amp.-or Over 600 V
Exemption for Reg. Maint. Elect.
SINGLE FAMILY Temp. Power Pole& Appurtenances -5 2.2 6 A
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit #,o o•o 0,o,2
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' (•,o o45,50
Professions Code):
El` nMisc. Conduits& Conductors o:o o
I, as ower of the property, will 'do the work and the 4S 5 0.
structure. is not intended'or offered for sale (Section Other,(See.Complete,Fee Schedule)'_,
7044, Business and Professions Code). 0 ail 1 ,'8 6
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,l have read this application and state that the TOTAL.FEE s'
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 abov me tinned roperty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
ignatur of Permittee .0 Date
.7.6A663-CE806 1/70 APPLICATION FOR ELECTRIC L. PER I`
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER BUILDING `
BUILDING AND SAFETY"DIVISION ADDRESS
JOHN A. LAMBIE, COUNTY ENGINEER LOCALITY
COLEMAN W. JENKINS, SUPERINTENDENT OF BUILDING ?5
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
OUTLETS - NO, EACH - FEE - -
$
OWNER
$ „
RECEPT._ - MAIL -
ADDRESS x-0 xc�l
LIGHT TOTAL . FIRST 20 .20
CITY' TEL. NO. M����. L
SWITCH_ OVER 20 .1.0 -
PLAN CHECK -
LIGHTING - ' .10
FIRST 20 20 - - AP.RLICANT
TOTAL
FIXTURES
OVER 20 ADDRESS
APPLIANCES CITY TEL. NO:
PERMIT
RANGE DRYER_WTR. HTR. APPLICANT
STA. COOK -DISP. F.A.,U. - ADDRESS -
SPACE HTR, AIR
COND.-CITY TEL. NO.
CLOTHES WASH. OISHWAS.H. - LICENSE NO. CLASS.. '
FAN-OTHER .1.00 I HEREBY ACKNOWLEDGE THAT I HAVE .READ THIS APPLICATION
AND STATE THAT THE,ABOVE IS CORRECT AND AGREE TO COMPLY
MOTORS, TRANSFORMERS RATING 'W ITH ALL COUNTY. ORDINANCES- AND STATE 'LAWS REGULATING
IND. HEATERS, ETC. HP. KW. KVA. ELECTRICAL WIRING'.
SIZE & TYPE OVER TOS
- I HEREBY CERTIFY THAT f AM PROPERLY-REG ISTERE'D AND/OR
0 - 1 100 LICENSED AS REQUIRED BY LOS.ANGELES COUN.TY'AND-STATE OF
CALIFORNIA OR THAT 1 AM THE LEGALOWNEROF, AND INTEND T•0
1 - 10 3.00 RESIDE IN, THE ABOVE DESCRIEED RESIDENTIAL PROPERTY.
O.
'SIGNATURE Q
10 - 50 5.00 OF PERMITTE
50 - 100 10.00 �
DISTRICT NO. CLASS GROUP ZONE =E
'E
100'- S00 I5.00 (J
W
SIGN, GAS SIGN AND ONE CIRCUIT 3.00 NOTES:- - 4:
TUBE, OR N
MARQUEE ADDITIONAL.CIRCUITS 1,00 '
SERVICENOTOVER600.VOLTSOR200AMP 2.00
APPROVALSDATE INSPECTOR'S SIGNATURE
SERVICEOVER600VOLTS OR200AMP 5.00
TEMP.POWER POLE
TEMP SERVICE, POLE, &APPURTENANCES 3.00 -
UNDERSLAB WORK -
TEMP LIGHT OR RECEPT. SYSTEM 3.00
ROUGH CONDIUT
WIRING
FIXTURES*
PERMIT FEE. (SUB TOTAL).
POWER AUTHORIZED
PLAN CHECK. FEE (50% PERMIT FEE) •
' UTILITY CO. NOTIFIED _%�AG 7,,0
PERMIT Ie �ING FEE 2.00 - -
FINAL -
SUPPLEMENTARY PERMIT ISSUING FEE 1.00 -
JOSEPH C. ROOHAN
TOTAL FEE _ r N SUPERVISING ELECTRICAL ENGINEER,
PLAN CHECK VALIDATION. CK. M.O. CASH PERMIT VALIDATION cK'. M.O. CASH
SEE BACK OF APPLICATION FOR COMPLETE SCHEDULE