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APPLICATION FOR ELECTRIC PERMIT
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEERBUILDING
BUILDING AND SAFETY DIVISION gDDREss
JOHN A. LAMBIE, COUNTY ENGINEER
WILLIAM A.JENSEN,SUPT OF BD]LOIIG LOCALITY
FOR APPLICANT TO FILL IN NEAREST `
PERMIT FEES CROSS ST.
OWNER iA'T ACL O
ITCM NUMBER EACH FEE MAIL
OUTLETS: 3 3 5-O ADDRESS
LIGHTS RECEPT. 6w. .10
LIGHTING FIXTURES f0 CITY TEL.NO.
ELEC.RANGES CLO.DRYERS ELECTRICIIA
WATER HEATERS .50 ADDRESS-3I Q
ELEC.SPACE HTRS. DISHWASHERS
CITY TEL. NO
GARBAGE DISPOSERS AUTO.-
STATE / 7J/'_ _/ D
WASHERS STA.COOKING UNITS .25 LICENSE NO. ( `
MOTORS: OVER INC. H.P. I DISTRI�TNO. GROUP ZONE P OCESSED BV
O— '/ .25
`J Y{�77
'/2- 2 .50 INSPECTION RECORD
2— 5 1.00
5— 15 1.50
IS— 50 2.50
50-200 5.00
SIGNS: NO.TRANS.
NO.LAMPS
SERVICE 0-600V 1.00
SERVICE OVER 600V 5.00
MISC
WIRINGPERMIT1.00
FIXTURE PERMIT 1.00
SUPPLEMENTARY PERMIT .50
TOTAL FEE Is
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION APPROVALS DATE INSPECTOR'S SIGNATURE
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING CONDUIT If 1 14 J nr 04
ELECTRICAL WIRING. V d//yV`
I HEREBY AS:
THAT I AM PROPERLY REGISTERED AND/OR WIRING
LICENSED AS OUI ED BY LOS ANGELES LINTY AND STATE OF FIXTURES
CALIFORNIA O TH THE LE AL NER OF THE ABOVE
DE6CRIBED RE EN IAL OPERTY. POWER
SIGNATURE - UTILITY CO.NOTIFIED
OFPERMITT �I1ii FINAL rJVr�v
®v bra+µDATION SUPERVISING ELTHUR C. I CTRIICAL ENGINEER
CK
NO CASH
LACO 85 6 0 MAR 3 0 2 A 2.2 0
T°"° °""°° APPLICATION FOR ELECTRIC PERMIT
COUNTY OF LOS ANGELES -
DEPARTMENT OF COUNTY ENGINEER BUILDING
BUILDING AND SAFETY DIVISION ADDRESS
:JOHN A. LAMBIE, COUNTY ENGINEER
CASSATT D. GRIFFIN,SUPT OF BUILDING LOCALITY I
FOR APPLICANT TO FILL IN CROSS T � 2 J
PERMIT FEES
ITEM NUMBER EACH FEE OWNER �7 O
MAIL
OUTLE S $ ADDRESS
LIGHTS NECEPT.GO6W. d .ID
LIGHTING FIXTURES Alfol 10 CITY TEL.NO. —
ELEC.RANGES CLO.DRYERS ELECTRICIAN
WATER HEATERS .50 ADDRESS.--3-/
ELEG SPACE HTRS. DISHWASHERS - CITY
O
AGE DISPOSERS AUTO.
STATE f /' o l-1
WAS-RERI-STA.COOKING UNITS .25 .Y� LICENSE NO. Ci V
MOTORS:-OVER INC. H-P. DIST�CT.NO. I G UP I T ONE `I P CE55ED BY
0 A .25 .
va— z so INSPECTION RECORD
2— 5 1.00
5— 15 1.50
15— 60 2.50
50-200 5.00
SIGNS:
NO.TRANS.
NO.LAMPS
SERVICE O-600V 1.00
SERVICE OVER 600V 5.00
MISC.
WIRING PERMIT 1.00
FIXTURE PERMIT 1.00
' SUPPLEMENTARY PERMIT .50
TOTAL FEE S G�
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION APPROVALS DATE INSPECTOR'S SIGNATURE
ANO STATE THAT THE ABOVE I6 CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING CONDUIT u ZlJ /YIYI ((
ELECTRICAL WIRING. WIRING /70r1n %7h""Fl.6Pf
1 HEREBY CERTIFY AT 1 AM PROPERLY GISTEflED AND/OR
LICENSED AS REQUIRE BY LOS ANGELES C NTY AND STATE OF FIXTURES
CALIFORNIA OR THAT I AM THE LEGAL O NER"OF THE ABOVE
DESCRIBED RE6IDENT L ROPERTY. //
\ POWER
UTILITYCO.NOTIFIED
OF u� /&SIGNATURE
Q
FINAL
ATION SU ERVISING ELECTRICAL ENGINEER
CK MO CASH
L ACo9 4.9 7.� APR 2 A 1 0.3 0 14
_ 4C40RKERS't C;JMPEIS$ATION DECLARATION )6A663 10/81 APPLICATION
p l�� I� I� ELECTRICAL
l� ,}� pp pp 1�pp gi
s�.. I hereby affirm the_11
hove a certificate of consent to self CE-8061, APPLICATION IrOR ELECTRIC 91L PERMI 11
insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified copy thereof (Sec. 3800,Ab. C.) ,
Policy
,,Igo si S'Y7o3- g�23c�
ompany FOR APPLICANT TO FILL IN JOB
❑. Certified copy is hereby furnished New Residential Bldgs. 8 Pools EACH NO. FEE ADDRESS
YCI Certified copy is filed with the c my building inspec- I & 2-Family, Sq. Ft. $ — $ LOCALITY
CC"��" tion de department. - Multi-foal Sq. Ft. I — NEAREST
Residemial Swimming Pools CROSS ST.
Date O Applicant J ' - 1 OWNER OR
FIRM NAME '
C RTIFICATE.OF EXEMPTIO FROM WO S' Outlets: RecLightSw._ MAIL
COMPENSATION SURANCEADDRESS
(This section need not be completed if the work involved by First 20
Total No.
the permit is.for one hundred dollars ($100)or less.) Additional CITY Tel No. _
a PLAN CHECK certify that in the performance of the work for which thls APPLICANT
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 ADDRESS
Total No. Additional
CITY Tel. No.
Date Applicant NOTICEFixed Appliances Not Over 1 HP PERMIT
Exempt'TOon, APPLICANT: If, after making this Certificate of APPLICANT
Exemption, you should become subject to the Workers' Range_ Heater—D.W.
Compensolion 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 —W.H. — 5_3,F 7t/2—
deemed.revoked. Hood Fan _Other—. CITY Tel, No.
LICENSED CONTRACTORS DECLARATION - LICENSE OR
Room Air Cone. Cla
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. REG. NUMBER
(commencing with Section 7000) of Division 3 of the Business power Apparatus 8 Large Appliances DISTRICT jyQ. PROLES BY d
and Professions Code, and my license is in full force and effect.
Size 8 Type HP, KW, KVA, or'KVAR' /' U
License Numbe I ic. Class T Up to Incl V FINAL
Contractorate /0 Over 1 to 10 Ind. DATE VALIDATION �'
❑ - Over 10 to 50 Ind. FINAL W'
I am exempt under Sec Over 50 to 100 Inc. BY a
B.BP.C. for this reason z
Over 100 z
_
Date:
Services, Swbd., MCC & Ponelboards D ',
0 - 200 Amp. Under 600 V
Signature 201 - 1000 Amp. Under 600 V
❑ - Over 1000 Amp. or Over 600 V _ (L/�
Exemption for Reg. Mains. Elect. �3 1'(13 Q
SINGLE FAMILY Temp. Power Pole 8 Appurtenances
HOME OWNER-BUILDER DECLARATION
(`r�'' !/ e a e
hereby affirm that I exempt frothe Contractor's License a '2
Sign with One Branch Circuit '# e "
Law for the followingg r rmeason (Section 7031.5, Business and Additional Sign Branch Circuits
Professions Code): ( is 3 5 0
❑ I, as owner of the property, will do the work and the Misc. Conduits & Conductors
structure is not intended or offered for saleSection Other (See..Complete Fee Schedule)_
7044, Business and Professions Code). ( D J e e a 1 5 pcso
CONSTRUCTION LENDING AGENCY �, Q o9_g 5
I hereby offirm that there is a construction lending agency for
the performance of the work for which this permit is issued PERMIT FEE (Sub-Total)
(Sec. 3097, Ci, C.).
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEEId
tender's Address
I certify that I have read this application and state that rhe TOTAL FEE 3 5
above informaI is correct. I agree to comply with all County
ordinances an tate lows regulating Electrical wiring, and
hereb th i representatives of this County to enter upon
the a o tioned property for inspection purpose;. SEE REVERSE FOR EXPLANATORY LANGUAGE .
tD
Si o re of Per ittee Date