HomeMy Public PortalAbout9202 ROSEGLEN ST_Electrical__ yPA4e&-I;J�_9,U7 APPLICATION FOR ELECTRIC PERMIT �.
COUNTY OF LOS ANGELES ��// �
DEPARTMENT OF COUNTY ENGINEER.;* BUILDING dt
BUILDING ANb SAFETY DIVISION //��fj �p ADDRESS V `
JOHN A.LAMBIE,CouNTY ENarNTYR
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1s — 170 2.250
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WIRFNG PERMIT 1.00
FIXTURE FV"IT 1.00
SU"LEMENTARY PERMIT DO
TOTAL FEE rt AMOYAJZ
1 FUUMT ACkNOWL00i THAT I HAVE RW THIA APPI,lC/1TIOR DATA IIISPECTOR a DIGM
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MA7 THAT THE ABOVE I CORRECT AI1b AGpEB TO G01PLT Cp�UIT
ALL COUKTT ORpINANCES AND .STATS LAWS EEGULATISG
ELECTRICAL IMLING. WIRING
1 Hmum CEFMFT THAT 1 Ai PRO T GI AI1D/02
UCEMOfU�i AS R"UIM LOS AKGE CO D ATE OF P7xTUREH
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SIGNATURE A 1ITILITYCO.NOTIFIED
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WORKERS'COMPENSATION DECLARATION - ,O,B, APPLICATION FOR ELECTRICAL PERMIT
I hereb� affirm that I have a certificate of consent to self �j
Insure, or a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY lul
or a certified copy thereof (Sec. 3800, Lab. C.)
PolIcy No. Company FOR APPtW-ANT TO FILL IN JOB
❑
Certified copy Is hereby furnished. EACH NO. f$ ADDRESS
New Residential Bldgs. 8 Pools
❑ Certlfled copy Is filed with the county building Inspec- 1 8 2-Famlly, Sq. FI.— _ — = LOCALITY
tion department. Multi-family Sq. Ft. — NEAREST
Residential Swimming Pools CROSS ST.
Date Applicant OWNER OR '
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw._ HWL h
COMPENSATION INSURANCE 20 ADDRESS oc
Add ti
(Thh section need not be completed M the vlrork Imrohred by Total No Additional QTY el. N
the permit Is for one hundred dollars (=100)or leas.)
I certify that In the performance of the work for which this RAN CHVX
APpLK1,NF
permit 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 ADDS
TAdditional
Total No.
CITY Tel. No.
Date lican Fixed Appliances Not Over 1 HP p�UT
NOTICE OAICANfn: lf, after making this Icate of
Exemption, you should become subject to the Workers' Range_ Heater_D.W. —
Compensation provision 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. w
deemed revoked. Hood _ Fan _Other— CfTY Tel. No
LICENSED CONTRACTORS DECLARATION LIM,IS1 OR CI
I hereby affirm that I am licensed under provisions of Chapter 9 Dlap. _ Room Air Cond. REG NUhYMRSZX 91
(commencing with Section 7000) of Division 3 of the Business Power Apparatus 8 Large Appliances DISTRICT NO. BY
and Profewloru effect.
Code,and my license is In full force and eect.
Size 8 Type HP, KW, KVA, or KVAR :5A' 8
License Numbert /V�� 7 7 I Ic. Classy Up to 1 Incl. FINAL [�
ver I to 10 Incl. DATE
OZ — VPAATK>N
Contract Date Over 10 to 50 Incl. W
F-1 FI I am exempt under Sec. Over 50 to 100 Inc. BY a'
B.BP.0 Over 100
for this reason NZ
Date: Services, Swbd., MCC 8 Panelboards
0 -200 Amp. Under 600 V
Signature 201 - 1000 Amp. Under 600 V
❑ 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 Orcult
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
Professions Code):
❑ Mlsc. Condults d Conductors 6 1 a„10 A
I, as owner of The property, will do the work and the
structure Is not Intended or offered for sale (Section Other (See Complete Fee Schedule)_.., , #,0 0 0 0 0 2
7041, Business and Professions Code). ( .0 0 1 7.5
CONSTRUCTION LENDING AGENCY
1 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) 0 0 -.1 7. 5 Q Ts
(Sec. 3097, Civ. C.).
PLAN CHECKING FES 12.1 9-86
Lender's Name
PERMrf 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
hereby authorize representatives of this County to enter upon
th above-men loned property for Inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
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