HomeMy Public PortalAbout9750 VAL ST_Electrical__ '°"""s 11110°11 10/" APPLICATION FOR ELECTRICAL PERMIT
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'COUNTY OF LOS ANGELES pg . T
DEPARTMENT OF COUNTY ENGINEER gDDRE55 �O s/
BUILDING AND SAFETY DIVISION
FOR APPLICANT TO FILL IN LOCALITY AE' 4. r
New Residential Bldgs &Pools EACH NO FEE NEA ST
1 &2 Family Sq F S 025 — S WNER OR
Multi family Sq Ft 02 — FIRMNAM r
Residential Swimming Pools 2500 MAILRE55 05
.ADO
Outlets RecA/Light-2-Sw L CITU 6 Tel No
First 20 50 PLAN CHECK
Total No Additional 30 APPLICANT
ADDRESS
Lighting Fixtures First 20 50 o CITY Tel No
Total No Additional 30 PERMIT
Fixed Appliances Not Over l HP A DRESWSs �-
Range—Heater_D W _ CITY Tel No
Oven _Dryer_W M
Top —FAU —WH — REG NUMBER an
Hood_Fan Other_ I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND STATE
Cap _ Room Air Cond 2501 1 THAT THE ABOVE IS CORRECT AND AGREE TO COMITY WITH ALL COUNTY ORION
ANCES AND STATE LAWS REGULATING RKTRTCAL WIRING
Power Apparatus&Large Appliances
Size&Type HP KW KVA or KVAR I HEREBY CI THAT I AM PROPERLY LRGISTIRED AND/OR LICENSED AS
Up to 1 IMI 250 ME LIEM OWNER OBY LOS F THE ANGELES
COUNTY AND O 111BED ATE OF CALIFORNIA ffiIDENTIAL PRO ERTY THAT I AM O
Over 1 to 10 Ind 500 U
Over 10 to 50 Incl 1250 PERMITTE • ¢
SIGNA7U CD
Over 50 to 100 Inc 2500
Over 100 4000 DIST NO Rq1DjBSeryKeSOV0 200Amp Under600V 1250 APPROVALS DI I P ATOURE
201 1 ODO Amp Under 600 V 2500
Over 1000 Amp or Over 600 V 5000 TEMP POWER POLE
UNDERSLAB WORK
Temp Power Pole&Appunenarces 1000
Sign1000 ROUGH CONDUIT
Add w �.with One Branch Grant 2 00 WIRING •/��) dQJ@YKZ
Additional Sign Branch Circuits ;
Misc Condum&Conductors 1000 FIXTURES
Other ISee Complete Fee Schedulei POWER AUTHORIZED
UTILITY CO NOTIFIED
FINAL
PERMIT FEE (Sub Totoll NOTES
PLAN CHECKING FEE (One Fou.rth Permit Feel
PERMIT ISSUING FEE $700
TOTAL FEE D
PLAN CHECK VALIDATION CK M O CkSH PERMIT VALIDATION 6C M O CASH
1 7 7 AUG 7 2 D 2 4.0 0 e-�B
SEE BACK OF APPLICATION FOR COMPLETE SCHEDULE
WORKERS COMPENSATION DECLARATION' aWBO6 10,81 APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self if C
insure or a certificate of Workers Compensation Insurance COUNTY OF LOS ANGELES C BUILDING AND SAFETY
or a certified copy thereof (Sec 3800 Lab C )
Policy No Company e �� // /G . FOR APP LIUM TO FILL IN
PolJOB
Certified co is hereby furnished EACH NO FEE ADDRESS 50 4L sr
PY Y New Residential Bldgs 8 Pools
❑ Certified copy is filed with the county building inspec- I &2-Family Sq Ft If — f LOCALITY t
tion department Multifamily Sq Ft — NEAREST
Residential Swimming Pools
CROSS S
T 441017f
Dole Applicant OWNER OR
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS '!J r MAIL
COMPENSATION INSURANCE Outlets Rec�Lighr Sw / 3 J ADDRESS
(This section need not be completed N the work Involved by ��j first 20
the Permit Is for one hundred dollar ($100)or Ins ) Total No Additional CITY Tel No
RAN CHECK
I certify That d the Performance note employ
of the work for which thismanner
APPLICANT
permit rs issued, I shell not employ any person in any manner
so m to become subject to the Worker mpensabon Laws Lighting fixtures first 20 ADDRESS
Total No_46!� Additional
\! S�Lant CITU Tel No
/NOTICE–YOrAPPLICANT If after eking Ihu Certificate of fixed Appliances Not Over 1 HP PERMIT
APRK.nfJi
Exemption you Rane_ Heater_D W _should become subject to the Workers 0
Compensation provisions of the Labor Code you must forth- Oven _ Dryer _ W M _ ADDRESS
with comply with such provisions or this permit shall be Top _ FAU _WH _
s
deemed revoked Hood _ Fan _Other— CINAFIJ Tel No
LICENSED CONTRACTORS DECLARATION LICENSE OR
I hereby affirm that I am licensed under provisions of Chapter 9 Disp _ Room Air Cond REG NUMBER Class el-10
(commencing with Section 7000)of Division 3 of the Business Power Apparatus 8 Large Appliances DISTRICT NO PROCE D BY d
and Professions Code and my license is m ful I force and effect
��//p' Size 8 Type HP, KW KVA or KVAR �' Q
License Number iK S31i LLicyCCllan c-10 � Up to 1 Incl FINAL ,Q 2 V
Contractor/(JJ7�/Y1 7�+F�'�'PYdG_gay PrQ- Over I to 101nc1 DAA — VALIDATION Q
❑ - Over 10 to 50 Incl FINAL V
I am exempt under Sec Over 50 to 100 Inc BY W
IL
B 8P C for this reason Over 100 to
Dote Services, Swbd MCC 8 Ponelboards
0 200 Aim Under 600 V
Signature A—T00 EP Under 600 V
❑ Exemption for Reg Mamt Elect Over 1000 Amp or Over 600 V ;2503 1 A
SINGLE FAMILY Temp Power Pole 8 Appurtenances # • • • • 2
HOME OWNER-BUILDER DECLARATION Sign wfih One Branch Circuit1 hereby affirm that I am exempt from the Contractor s License
Law for the following reason (Section 7031 5 Business and Additional Sign Branch Circuits 2•• • 4 2 0 0
Professions Code)
❑ 1, as owner of the property, will do the work and the Muc Conduits 8 Conductors - 4 2 0 0 6
structure n not intended or offered for sole 09,08 83
(Section Other (See Complete Fee Schedule)_ ►
70Business and Professions Code)
=
44
CONSTRUCTION LENDING AGENCY _
I hereby affirm)hot 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
Lenders Name
PERMIT 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
the abovymsnlionecl property for inspection purposes
C SEE REVERSE FOR EXPLANATORY LANGUAGE
nature o ittee Date —O�
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