HomeMy Public PortalAbout10607 ROSEGLEN ST_Electrical__ WORiltS' COMPENSATION DECLARATION 76A663 10/81
rheryby rfflrm that I have a certificate of consent to self CE-906G APPLICATION FOR ELECTRICAL PERMIT
'thsure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY II
or a certified copy thereof (Sec. 3800, Lab. C.) u
Policy No. Company FOR APPLICANT TO FLL IN JOB
Certified c Is hereby fumished. EACH NO. FEE ADDRESS
copy y New Residential Bldgs. d Pools❑ LOCALITY—
Certified copy Is filed with the county building Irnpec- 1 8 2-Family, Sq. Ft.
Ilan department. Multi-family Sq. Ft. NEAREST
Residential Swimming Pools CRcm ST.
Date Applicant OWNER OR
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light S---Fir-it 20 w.� MAIL
�
COMPENSATION INSURANCE6 ADDRESS
(This section need not be completed If the work Involved by Total NcAddltlonbL CITY Tel. No
the permlit Is fpr one hundred dollars (=100)or 4ess.) ��CHECK
I certify that In the performance of the work for which this '
permit Is Issued, I shall not employ any person In any manner APPLICANT
- -
so as to become subject to the W Compensation Lc Lighting Fixtures First 20 ADDRESS
Total No. Additional
Date all CITY Tel. No. _
Fixed Appllanc Not Over 1 HP PERY T
NOTI TO APPLICANT: If, after" ki t Is Certificate of APPLICANT
Exemption, you should beco subs to the Workers' Range_ Heater_D.W.
Compensation provisions of the Labor Code, you must forth- Oven _ Dryer -t–W.M.— ADDRESS
with comply with such provisions or this permit shall be Top — FAU —W.H. —
deemed revoked. Hood _ Fan _Other_ CfTY Tel. No.
LICENSED CONTRACTORS DECLARATION
hereby affirm that I am licensed under provisions of Chapter 9 Dl:p. _ Room Alr Codd. Mat Class.
(commencing w1t5i Section 7000) of Division 3 of the Business Power Apparatus 8 Large Appliances DISTRICT ✓ PASSED BY
and Professions Code,and my license is In full force and effect.
Size 8 Type HP, KW, KVA, or KVAR r 8
License Number I Ic. Class Up to 1 Incl. FDIATE J�✓ /
Over 1 to 10 Incl. ` C/�/, VALIDATION
Contractor Date Over 10 to 50 Incl. FI
NAV
❑ I am exempt under Sec. Over 50 to 100 Inc. BY
B.BP.C. for this reason Over 100 Z
Date: Services, Swbd., MCC&Panelboards
0 -200 Amp. Under 600 V
Signature 201 - 1000 Amp. Under 600V
❑ Over 1000 Amp. or Over 600 V
Exemption for Reg. MalnT. Elect.
SINGLE FAMILY Temp. Power Pole 8 Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Clrcult
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
�essloru Code): y, we work M
I, as owner of the property, do the and the lsc. Conduits 8 Conductors
structure Is not Intended or offered for sale (Section Other (See Complete Fee Schedule)-
70441, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby afflrm-that there Is a construction lending agency for
the performance of the work for which this permit Is Issued PERMfT FEE (Sub-Total) / 2_
(Sec. 3097, Civ. C.).
PLAN CHECKING FEE
Lenders Name
PERMfT ISSUING FEE �D
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
hereby authorize representatives of this County to enter upon
th ve mentionedpro arty fpr Inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
—/
re of ml ee Date
COUNTY OF LOS ANGELES APPLICATION FOR PERMIT
Department of County Engineer ELECTRIC
DIVISIONSION OFFBUILDING & SAFETY
WILLIAM J. FOX, County Engineer
FOR APPLICANT TO FILL IN DISTRICT NO. GROUP ZONE I PERMIT NO.
ELECTRICIAN ---- ---
_ / RECEIVED BY READY FOR DATE ISSUED
ADDRESS �-�J� 1. FIRST INSPECTION
CITY - _ .TEL NO.
COUNTY LICENSE NO. EXPIRES BUILDING
PERMIT FEES ADORE5S
FEE
NUMBER EACH LOCALITY
LIGHT OUTLETS NEAREST
CRoss ST.
RECEPTACLES
WALL SWITCHES _ _OWN_E_R__
TOTAL OUTLETS r '!_. 5C $ MAIL y
ELEC. RANGES 25 ADDRESS-___
ELEC. HEATERS 25 CITY TEL NO.
FIXTURES 5
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS
MISC. APPLICATION AND STATE THAT THE ABOVE IS CORRECT
NUMBER OF LIGHT CIRCUITS AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES
NUMBER OF RECEPTACLE CIRCUITS AND STATE LAWS REGULATING ELECTRICAL WIRING.
MOTORS 1 CERTIFY THAT I POSSESS THE ABOVE VALID LOS
NUMBER HORSEPOWER FEE ANGELES COUNTY LICENSE, OR I AM THE LEGAL OWNER
NEw MVD. HP OVER INC. EACH OF THE RESIDENTIAL PROPERTY DESCRIBED ABOVE.
I/y 6 LESS $ .25 /
SIGNATURE
%2 2 .50 PERMITTEE
- --
2 s 1.00 INSPECTION RECORD
5 15 1.50
15 50 2.50
50 200 5.00
200 BOO 10.00 J
500 1 DOC) 15.00 Z
OVER 1000 20.00
M.G. BET/FREQ. CHANGER-HP
WELDERS:AC-KVA
GENERATORS - KW
TRANSFORMERS - KVA
TEMP. MOTORS (75% DF DRIB.)
MOVED MOTORS (75% or DRIB.)
MISC.
SIGNS
NO. NO.TRANS. APPROVALS
NO. NO. LAMPS
FOR EACH PERMIT: DATE INSPTOR'SNAME
WIRING $1.00 CONDUIT
FIXTURES $1.00 WIRING
SUPPLEMENTARY .50 FIXTURES
POWER
TOTAL FEE w UTILITY CO.NOTIFIED i
FINAL k T
76A663 DBS#5A 2-53
40
COUNTY OF LGS ANGELES APPUCATION FOR PERMIT
Department of County Engineer
y DM$ION OF BUT-.DING & SAFETY ELECTRIC i
WILLIAN J. FOX, Oeub Emelmew
FOR I LIN D ICT NO. GROUP ZONE PERMIT NO.
ELECTRICIA � T _ �� �
[C[ SY READY FOR DAT1 IS�trm
ADD F1RST INSfEDTION
DITY N
13OL1 TY LIO ■UILDINM
PERMIT FEES ADDRt■s
FII
HUMMER EACH U 3OAJ ITY
LIGHT OUTL[TI\ MEAREST
REAEPTADL[ ROY
S ■T
WA-L SWITCHE7 OWNER
TOTAL OUTLET■ 913 MAIL F
ZLEM RANGES Zi ADD
[LED. HEATERS Y
CITY` L. N0.
F I XTIU Rt• 't
I HERESY AoxmcrwLJCDP& THAT I HAV[ READ THIO
misch APPLICATION AND ■TAT[ THAT THE AMOVE I■ ODRR[OT
HUMMER OF LIGHT DIROUIT■ AND ADRs[ TO COMPLY WITH ALL COUNTY ORDINANDE■
NUMBER DF R[DEPTAOL[ DIRCUITE AND STATE LAWS REMULATINM ELEDTRICAL WIRINM.
MOTORS I C[7lT1FY THAT I ROr[!• THE ASOVE VALID LOM
HUME" HO"[POW[R FEE ANGEL[■ DOUN' L ENSE, OR AM TH[ OWNER
rD
Nw MVD. HP ViR IWn. OF THE RESIDENT [>� ■
1 i LEES .ZS .
■IMMATURE OF
ya 9 ,� P[RMI
s B 7"'
1.00 INSPECTION RE
s t s 1.90
115 SO 9.60
■C ZOO 5.00
ZCC BUD 1D.DO J
BSD1 DDD 1 0.DC
E =
OVR 1000 seam
M.D. ■[T rR CHANGER-HP
WELDERSI AD-CVA O
MENERATORS - KW
r
TRANSFCRM[RS - KVA
p TEMP. MOTOR/ (76 OF amim.
MOV[ MOTOR■ 715of oRl
Mina.
BIONS
N0. N0.TRANa
APPROVALS
NO, LAMPS T
FOR EACH FKRMIT� DAT[ IN R'S NAM[
} WIRING1,00 •--� CONDUIT
C FIXTUREX 1.00 WIRING 14
vHJrftICM9HTARY -*Q FD(TL RO
POWER
TOTAL FEE * UTILITY C0. NOTIFIm
� FINAL
76^"MDo#■A =-33