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76A66C CE#'806 5 61 APPLICATION FOR ELECTRICAL PERMIT
COUNTY OF LOS /ANGELES
DEPARMENT OF COUNTY ENGINEER BUILDING
BUILDING AND SAFETY DIVISION ADDRESS 's n f Al
JOHN A LAMBIE COUNTY ENGINEER
WILLIAM A JENSEN SUP T OF BUILDING LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST
PERMIT FEES OWNER
I T E M NUMBER EACH FEEMAIL d
OUTLETS S s ADDRESS o V
LIGHTS RECEPT SW 10 1-,CITY'
ti/�1L. � NO
LIGHTING FIX RES 10 r--�r �r �s
ELEC RANGES J CLO DRYERS ELECTRICIAN C t4
WATER HEATERS SO ADORES-9- Cal ofr
ELEC SPACE HTRS DISHWASHERS CITY eA':s J9 u J JF/7 • II EL NO,d+ (o �J-§
GARBAGE DISPOSERS AUTO STATE /
WASHERS STA COOKING UNITS 25 LICENSE NO / ��yj J D ,.1
MOTORS OVER INC H P 25 DIST•I� U =ESSEDr G BY
0— '/z
1/2- 2 S0 INSPECTION RECORD
2— 5 ' 100 0
5— 15 150 V
15 5019
19
O
SO— 200 Boo U
W
SIGNS NO TRANS H
NO LAMPS r z
SERVICE O 600V ' 100 F'
SERVICE OVER 600V 500
M 15C
WIRING PERMIT ` "' 100 ad
FIXTURE PERMIT 100
SUPPLEMENTARY PERMIT 50
TOTAL FEE $
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION APPROVALS DATE INSPECTOR S SIGNATURE
AND'STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY 1
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING CONDUIT
ELECTRICAL WIRING Lev
WIRING
I HEREBY CERTIFY THAT I AM PROPE REGISTERED AND/OR
LICENSED AS REQUIRED BY LOS ANGE COUNTY AND STATE OF FIXTURES
CALIFORNIA OR THAT I AM THE LEG OWNER OF THE ABOVE
TIAL
DESCRIBED RESIDE ROP Y POWER A
SIGNATURE o UTILITY CO NOTIFIED IV 4<
OF PERMITTEE ,. Ca �t®
FINAL 7 ILK
VALIDATION--, ARTHUR C VEIT
I v CK MO CASH SUPERVISING ELECTRICAL ENGINEER
ri
- 0 2>7 ;, 1� 250
+" WORKERS'COMPENSATION DECLARATION 76A663 10/81 APPLICATION FOR ELECTRICAL PERfI� �-
�l°re�eby 'affirm that I have a certificate of consent to self insure, CE-806G
• ck a certificate of Workers' Compensation Insurance, cr a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
vopy thereof(Sec. 3800.Lab.C.) _
Policy No.' Company '_� � FOR APPLICANT TO FILL IN .JOB
❑ Certified copy is hereby furnished. EACH NO. FEE ADDRESS
New Residential Bldgs.& Pools
$FLOCALITY
S
il
F
2- amy, q. t. — $.
Certified copy is filed with the county building inspection 1 & _ NEAREST I
department., Multi-family Sq.Ft.
CROSS ST.
Residential Swimming Pools OWNER OR
Date Applicant FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:ReLight � Sw. 4 MAIL
c
COMPENSATION INSURANCE ADDRESS
(This section need not be completed if the work involved by the Total No. RCY FAidditional CITY Tel.No.
rst 20 _
permit is for one hundred dollars($100)or less.)
I certifythat in the performance of the work for which this permit PLAN CHECK
p p APPLICANT
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 ADDRESS
Additional
Total No. CITY Tel.No.
Date Applicant Fixed Appliances Not Over 1 HP
NOTICE TO APPLICANT: If, after making this Certificate of PERMIT
Exemption,you should become subject to the Workers'Compensation Range_ Heater_ D.W. _ APPLICANT
provisions of the Labor Code, you must forthwith comply with such Oven _ Dryer _ W.M._ ADDRESS
provisions or this permit shall be deemed revoked. Top — FAU _ W.H.
CITY Tel.No.
LICENSED CONTRACTORS DECLARATION Hood — Fan _ Other_ L
I hereby affirm that I am licensed under provisions of Chapter 9 LICENSE OR
Disp. — Room Air Cond.
(commencing with Section 7000) of Division 3 of the Business and REG.NUMBER
Professions Code,and my license is in full force and effect. DISTRICT NO. C SED BY
Power Apparatus& Large Appliances . �y
�.
L� ^7 Size& Type H �
P,KW,KVA,or KVAR e \ U
License Number 7�Vic.Class Up to 1 Incl. FINAL
�'
� Over 1 to 10 Incl. DATE �l V VALIDATION OO
Contractor-&!, Z- �� Date Over 10 to 50 Incl. 1
FINAL ()
❑ I am exempt under Sec. Over 50 to 100 Inc. BY W
B.&P.C.for this reason Over 100 n"
N
Services, Swbd.,MCC & Panelboards Z
Date: ar 0- 200 Amp.Under 600 V
Signature 201 - 1000 Amp. Under 600 V
E-1Exemption
1000 Amp. or Over 600 V
Exemption for Reg.Maint.Elect.
SINGLE FAMILY ' Temp.Power Pole& Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit 2
1 hereby affirm that I am exempt from the Contractor's License Law Additional Sign Branch Circuits ACCT a
for the following reason(Section 7031.5, Business and Professions m8
Code): 3307 43.Z
❑ Misc. Conduits& Conductors
1,as owner of the property,will do the work and the structure """"" 1 ITEMS Other (See Complete Fee,Schedule) ""`
is not intended or offered for sale (Section 7044, Business ,
and Professions Code). TOTAL 43.25
CONSTRUCTION LENDING AGENCY 43.25 7L3r25
1 hereby affirm that there is a construction lending agency for the �f�
performance of the work for which this permit is issued(Sec.3097, PERMIT FEE (Sub-Total) - co __.,
Civ. C.). .00
PLAN CHECKING FEE.
Lender's Name PERMIT ISSUING FEE 0wo—owl 11/ 1/89
Lender's Address r 6498 I. 7 �3
I certify,that I have read this application and state that the above TOTAL FEE
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
prop arty for ins on pur ses.,
_ SEE REVERSE FOR EXPLANATORY LANGUAGE
ignature of Per ittee Dafe