HomeMy Public PortalAbout5642 ROSEMEAD BLVD_Electrical__ IA 8l-CESD6 5.62- APPLICATION FOR ELECTRIC L PERMIT �
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER BUILDING
BUILDING AND SAFETY DIVISION ADDRESS
JOHN A. LAMBIE. COUNTY ENGINEER ,
WILLIAM A.JENSEN,SUPT OF BUILDING LOCALITY
NEAREST
Vi -'OR APPLICANT TO FILL IN CROSS ST.
RECEPT TOTAL NO. EACH FEE
OUTLETS FIRST 20 R 2O $ �ovOWNER
LIGHT MAIL
ADD'L 10 ADDRESS
SWITCH. OVER 20 ,
TOTAL CITY TE"o.
O.
LIGHTI G Flesr 20 .20
FIXTURESADD'L .10 ELECTRICIA
OV R 2O
RANGES CLO.DRYERS WTR.HTRS. 1.00 ADDRESS
GARB.DISP.167 STA.COOK r
CITY TEL
DISHWASH. AUTO.-WASH. STATE
SPACE HTRS. STA.APP.(V=H.P.MAX) .50 LICENSE NO.
I MOTORS- OVER NOT OVER H.P. DISTRICT O. G UP P SEED BY
�. O 1 1.00A4
I a 1.50 INSPECTION RECORD
s e 2.00
8 is 2.50
15 so 3.00 p 0
50 100 5.00Y O
SIGNSI NO.TRANS" ( U
NO.LAMPS G 6 7, Al
D_
SERVICE O-SOOV-NOT OVER 200A 1.00
Z
SERVICE O-SOOV-OVER 200 A. 2.00
SERVICE OVER SOOV 5.00
misc.
PERMIT ISSUING FEE 2.00
SUPPLEMENTARY PERMIT ISSUING FEE. 1.00
TOTAL FEE 30
1 HEREBY ACKNOWLEDGE THAT 1 HAW READ THIS AMPLICATION APPROVALS DAT9;' INSPECTOR'S SIGNATURE
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY `
CONDUIT
WITH ALL•COUNTY ORDINANCES•AND STATE LAWS REGULATING
ELECTRICAL WIRING. WIRING
IHEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR - '
LICENSED AB REQUIRED BY LOS ANGELES COUNTY AND STATE OF FIXTURES
CALIFORNIA OR THAT IAM HE LEGAL OWNER OF THE ABOVE +
DESCRIBED RESIDENTIAL P POWER
SIGNATURE UTILITY CO.NOTIFIED -7
OF PERMITTEE
FINAL. '
^JIDATION ART*Uq C. VETT
CK�MO CASH SUP� V18ING ELECTRICAL ENGINEER
LIAU'o 7 9 7 5:o FE 6 - 2 D 7 3.3 0^' `�
�A 'WORKER'S COMPENSATION DECLARATION 270o6o83e DPw(t2.91) APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm t&I have a certificate.of consent to self insure,
or a certificate of Worker's Compensation Insurance,or a certified COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS BUILDING AND SAFETY DIV.
copy thereof(Sec:3800 Lab.C.)
Policy No. - Company FOR APPLICANT TO FILL IN J� ` r
❑ ADDRESS
Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE LOCALITY �.
1 &2-Family,Sq.Ft. — $ $
❑ Certified copy is filed With the county building inspection _ NEAREST .�
department. Multi-family Sq.Ft. CROSS ST. 0 R'� �� /
Date Applicant Residential Swimming Pools ASSESSOR
MAP BOOK PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec._Light Sw. 4 OWNER OR
COMFirst 20 MAIL
COMPENSATION INSURANCE FIRM NAME
(This section need not be completed the work Involved by the Total Nm Additional ADDRESS S�
permit Is for one hundred dollars($1000)or leas.) -
I certify that in the performance of the.work for which this permit CITY Tel.No. `r9
Is issued, I shall riot employ any person In any manner so as to PLAN CHECK
become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 APPLICANT
-Total No. Additional
ADDRESS
Date Applicant RESIDENTIAL APPLIANCES NOT OVER 3 HR.
NOTICE TO APPLICANT: If, after making this Certificate of CITY Tel.No.
Exemption,you should become subject to the Workers'Compensation OTHER APPLIANCES NOT OVER 3 H.P.
provisions of the Labor Code,you must forthwith comply with such PERMIT
P Y P Y Power.A APPLICANT
provisions or this permit shall.be.deemed revoked. ' pparatus&Large Appliances
LICENSED.CONTRACTORS DECLARATION Size&Type HP;KW,KVA,or KVAR ADDRESS
I hereby affirm that I am licensed under provisions of Chapter 9 Over 3 to 10 Incl.
(commencing with Section 7000)of Division 3 of the.Business and CITY Tel.No.
Professions Code,and my license is in full force and effect. Over 10 to 50.Ind.
}
Over 50 t0 100 Incl. { LICENSE OR Class'
REG.NUMBER Q
Over 100 DISTRICT NO. PROCESSED.BY 0
License Number . Lic.Class V
Services,Swbd.,.MCC&Panelboards ;e
' V� r Q
0-399 Amp.Under 600 V FINAL 0
Contractor Date DATE y/
❑ I am exempt under Sec. 400-1000 Amp.Under 600 V 4_ � � ` ACC ALDATION 0
Over 1000 Amp..or Over 600 V FINAL III
B.&P.C.for this reason ' BY . / le 3303 44.40m
BRANCH CIRCUIT FEES /4'�`C 03
Date' 15A,or 20A,120V,L, inngo -Race p_t. +r„� '�' 1 ITEMS z_
1 T re ch vcw1G •�D
Signature 40
11 To 40 Branch Circuits TOTAL '�
❑ 41 Or More Branch Circuits CASH 44.40
Exemption for Reg.Maint.Elect. 15A,20A,20 VV To ZM Lighting Br.Circuits
• CHANGE o00
SINGLE FAMILY Temp.Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License Law
for the following reason(Section 7039.5, Business and Professions Additional Sign Branch Circuits 01 _ 001 4/ 96
Code):
I,as owner of the property,will do the work an..dthe structure Misc.Conduits&Conductors 1 AM 1 .25
is not Intended or offered for sale(Section 7044, Business Other(See Complete Fee Schedule) F
and Professions Code). ,
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the 0 00 1 4 4/
performance of the work for which this permit,s issued(Sec. 3097, ' PERMIT FEE (Sub-Total) 2 1102
Civ.C.)
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE •
Lender's'Address. .
I certify that I have read this application and under penalty of purjury state TOTAL FEE
that the above information is correct. I agree to comply with all County
ordinances and State laws regulating Electrical wiring,and hereby authorize
rept tatives of Is C nty,to enter upon tFle` aave mentioned property
Wr'ns ct' npurp s. f7,, \\II SEE REVERSE FOR EXPLANATORY LANGUAGE
II.—NATURE.I:PERMI E DAT