HomeMy Public PortalAbout6247 ROSEMEAD BLVD_Electrical__ 76A663A-CESOGA 4/72 APPLICATION FO ELECTRICAL PERMIT
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER BUILDING
BUILDING AND SAFETY DIVISION ADDRESS / �IYI•!�
LOCALITY Zf, C
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
OUTLETS NO. EACH FEE ,I
t OWNER � 'e'/v_ 4/V
RECEPT.-T_ MA2 $ $ MAIL
ADDRESS
LIGHT TOTAL FIRST' �j(�
CITY TEL. NO.
SWITCH OVER 20
PLAN CHECK
LIGHTING l TOTAL FIRST 20 APPLICANT
)}
FIXTURES
OVER 20 ADDRESS
RESIDENTIAL APPLIANCES CITY TEL. NO.
PERMIT
RANGE DRYER_WTR. HTR. APPLI ANTL e�ifi/V
STA. COOK DISP.-L-F.A.U. ADDRESS6 / OV 131,
SPACE HTR, AIR COND. CITY i / TEL. N -,
CLOTHES WASH. DISHWASH. LICENSE N0. CLASS.
FAN OTHER I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION O}.
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY p
MOTORS, TRANSFORMERS RATING WITH ALL COUNTY ORDINANCES AND- STATE LAWS REGULATING C.3
IND. HEATERS, ETC. HP. KW.KVA. ELECTRICAL WIRING. a.
SIZE & TYPE OVER TO '
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR CI--
0 - 1 LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF W
CALIFORNIA OR THAT I AM THE,LEGAL OWNER OF, AND INTEND TO
' - 10 RESIDE IN, THE 2 DESCRIBED R ENTIAL PROPERTY. Z
SIGNATURE
10 - 50 OF PERMITTEE
50 - 100
DISTRICT NO. ICL S, SBED BY
d
=SIGN .100 - S00 `/,(j
SIGN, GAS AND ONE CIRCUIT NOTES: �� o W/IZ6�)
TUBE, OR
MARQUEE ADDITIONAL CIRCUITS
SERV I CE NOT OV ER 600 VOLTS OR 200 AMP
APPROVALS DATE INSPECTOR'S SIGNATURE
SERVICEOVER 600 VOLTS OR 200 AMP
TEMP.POWER POLE
TEMP SERVICE,POLE,&APPURTENANCES
TEMP LIGHT OR RECEPT. SYSTEM UNDERSLAB WORK
ROUGH CONDIUT
WIRING
FIXTURES
POWER AUTHORIZED
PERMIT FEE (SUB TOTAL)
UTILITY CO. NOTIFIED
PLAN CHECK FEE p�
FINAL
PERMIT ISSUING FEE
TOTAL FEE
PLAN CHECK VALIDATION CK. M.0. CASH PERMIT VALIDATION CK. M.0. CASH
54 5 n 0 C T 6, 2. DI � 7.1 �i A�G
I j
WORKERS'COMPENSATION DECLARATION 76AM3 DPW 3/87 APPLICATION FOR ELECTRICAL PERMIT Q
I hereby affirm that I have a certificate of consent to self
irwure, or a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES I DEPT. OF PUBLIC WORKS
or a,.cert'ified copy thereof(Sec. 3800, Lab. C.)
PolicyCompany-- fY/N1� t FOR APPLICANT TO FILL IN j JOB
Certified copy is hereby furnished. �C�� f New Residential Bldgs. &Pools EACH NO. FEE ADDRESS
❑Certified copy is filed with the county building inspec- I 1 &2-Family,Sq. Ft. $ _ $ LOCALITY
tion department. I Multi-family Sq. Ft. NEAREST
DateT �?'�, � Residential Swimming Pools j CROSS ST.
OWNER OR
Applicant 117,
' FIRM NAME
CERTIFICATE OF EXEMPTION FROM ORKE ' Outlets: Rec 7 Light/3 Sw. �It
COMPENSATION INSURANCEFirst 20 O W J 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 not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. I Lighting Fixtures First 20 ADDRESS
Additional j
Date Applicant Fixed Appliances Not Over 1 HP PERMIT
Total No. CITY Tel. No.
I
NOTICE TO APPLICANT: If, after making this Certificate of I ' APPLICATION '7N�
Exemption, you should become subject to the Workers' Range— Heater—D.W. —
Compensation provisions of the Labor Code, you must forth- I Oven — Dryer —W.M.— ADDRESS eor
with comply with such provisions or this permit shall be Top — FAU —W.H. — _
deemed revoked.
eae
Hood — Fan —Other— CITY ow
LICENSED CONTRACTORS DECLARATION I I LICENSE
— G.NUMBER Class. 9
1 hereby affirm that I.am licensed under provisions of Chapter 9 Disp. — Room Air Cond. RE
(commencing with Section 7000)of Division 3 of the Business Power Apparatus&Large Appliances DISTRICT NO, P ESSED BY >_
and Professions Code,and my license is in full force and effect. r,A� a
Size&Type HP, KW, KVA, or KVAR r~%f O
License NumberJIQW�),5 Lic. Class Up to 1 Incl. FINAL
I U
�� Z2- 3-
3 Over 1 to 10 Incl. i DATE VALIDATION 0
Contractor r Date Over 10 to 50 Incl. H
❑ - �-� I FINAL U
I am exempt under Sec. Over 50 to 100 Inc. gY U
B.&P.C. for this reason Over 100 d
Date: Services, Swbd., MCC&Panelboards i , Z
0-200 Amp. Under 600 V
Signature I 201 - 1000 Amp, Under 600 V
I "
❑ Exemption for Reg. Maint. Elect. Over 1000 Amp. or Over 600 V
SINGLE FAMILY Temp. Power Pole 8 Appurtenances i
HOME OWNER-BUILDER DECLARATION ,r.
I hereby affirm that I am exempt from the Contractor's License Sign with One Branch Circuit j N4k
Law for the following reason (Section 7031.5, Business and I Additional Sign Branch Circuits I _T7
ns
ProfessioCode): j
vvl!f _X.a QU
Misc. Conduits&Conductors
IDI, as owner of the property, will do the work and the
structure is not intended or offered for sale Section 7044, Other(See Complete'Fee Schedule)_ , -o�--aI
_
Business and Professions Code). I
CONSTRUCTION LENDING AGENCY r•H E C
1 '132.&D
I herebyaffirm that there is a construction lending agency forCHANGE
g g s d s� 1
the performance of the work for which this permit is issued PERMIT FEE (Sub-Total)
(Sec. 3097, Civ. C.).
PLAN CHECKING FEE :-IL
I-lLl_ �tyl yY,r;f
Lender's Name
Lender's Address PERMIT ISSUING FEE I 5150 i AM ,,`v:46
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
the above-mentioned
property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature bf PEVMitTeer, Date ®'