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7QAS63 CE9091039 APPLICATION FOR ELECTRIC PERMIT 1
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING
BUILDING AND SAFETY DIVISION ADDRESS
JOHN A. LAMBIE. COUNTY ENGINEER
WILLIAM A JENSEN SUP T OF BUILDING LOCALITY .4.•`�
FOR APPLICANT TO FILL IN NEAREST '
CROSS ST, a
PERNIIT FEES /rye!
ITEM NUMBER EACH FEE OWNER
OUTLETq $ $ MAIL �r �r /l
LIGHTS 7RECEPT SW 10 ADDRESS /4'/�,I j
LIGHTING FIXTURES �, 10 '� CITY �ivL K TEL N
ELEC RANGES CLO DRYERS ELECTRICIA ''
WATER HEATERS SO ADDRESS '
ELEC SPACE HTRS DISHWASHERS CITY / EL NO
GARBAGE DISPOSERS AUTO- STATE
WASHERS STA COOKING UNITS 25 LICENSE NO
MOTORS OVER INC H P DISTRICT NO I GROUP I ZON P CESSED BY
0— 1/2 25 -cam si
1/2— 2 SO SPECTION RE ORD
2— is 100 �G /
5— 15 150
IS— 50 250 /
50-200 500
NO TRANS ~'AV
SIGNS
NO LAMPS �y�,j�y ✓�w I� J J C
SERVICE 0-600V too f
SERVICE OVER 600V Soo
MISC f
WIRING PERMIT 100
FIXTURE PERMIT too
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
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING CONDUIT
ELECTRICAL WIRING
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR WIRING
LICENSED AS REQUIREDBY LOS ANGELES COUNTY AND STATE OF FIXTURES
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESID TIAL PROPERTY POWER
SIGNATURE r f UTI LITYCO, NOTIFIED r
OF PERMITTEE C
FINAL
®r CK M SU H U R C VETT
CK Mo CASH SUPERVISING ELECTRICAL ENGINEER
Af' 7 8 �n 4 : CCT D
WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12-91)
76A663 APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that-1 halve a celi-lificate &consent to self insure,
or a certificate-of.Weker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV.
copy thereof(Seo: 3800 Lab. C.)
Policy No. Company FOR APPLICANT TO FILL IN JOB EACH FEE ADDRESS , l
J k) /7Ut I.
Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. LOCALITY
Ale-
El Certified copy is filed with the county building inspection 1 &2-Family,Sq.Ft. —1$ $
NEARESTdepartment. Multi-family Sq-Ft.
caoss Sr.
Date Applicant Residential Swimming Pools ASSESSOR
MAP BOOK PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER ORS
w.Rec. Light Sev.
COMPENSATION INSURANCE g First 20 FIRM NAME 01 +1 -�Q ✓Oi
(This section need not be completed if the work involved by the qua MAIL
ADDRESS S4.Y i 8
permit is for one hundred dollars($100)or less.) Total No. Additional v
I certify that in the performance of the work for which this permit S(A,L0 ��}�� CITY Tel.No. 2?S—Z53
/become
issued, I shall not employany person in an manner so as to subject to the Workers'Com en ion ws. Lightin Fixtures First 20 PLAN CHECK
J P 9 � v� APPLICANT S!•crY�'l e.
_ Total No. Additional f�0
_ f �1 ADDRESS
Date `� w Applicant MA
NT ZAPPLIANCESf�OT OVER 3 HP.NOTICE TO APPLICANT: If, after making this Certificate of E CITY Tel.No.
Exemption, you should become subject to the Workers' Compensation APPLrIANCES NOT OVER 3 HP.
provisions of the Labor Code, you must forthwith comply with such PERMIT �y�, Y�r
provisions or this permit shall be deemed revoked. Power Apparatus&Large Appliances APPLICANT 0 JV
LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS Sir, �
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 Incl.
SE OR
Over 50 to 100 Ind. REGNNU BER Class. 13-
License Number Lic.Class Over 100 DISTRICT NO. PR ES Y O
Services,Swbd.,MCC&Panelboards ( c cc
Contractor Date 0-399 Amp.Under 600 V CS DATE O
400-1000 Amp.Under 600 V 0
❑ I am exempt under Sec. Over 1000 Amp.or Over 600 VFINAL VALIDATION W
B.&P.C.for this reason BRANCH CIRCUIT FEES BY W
Date: 15A,or 20A, 120V,Lighting or Recept. Z
1 To 10 Branch Circuits
Signature 11 To 40 Branch Circuits
❑ 41 Or More Branch Circuits
Exemption for Reg.Maint.Elect. 15A,20A,208V To 277V Lighting Br.Circuits
SINGLE FAMILY Temp.Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATIONi-••-• .y
I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit ;;;.t,i n s
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits _,--2
•�4(1•✓ L ii�{��
I,as owner of the property, will do the work and the structure Misc.Conduits&Conductors _
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) -3g ��
....E"e_ I L. .,Z 9 a '°''."'~3
and Professions Code).
-.I vr••�•.a: a�;i
CONSTRUCTION LENDING AGENCY C-1 jl # __—_ ..
1 hereby affirm that there is a construction lending agency for the i;..
performance of the work for which this permit is issued Sec. 3097, n_1_
p P ( PERMIT FEE (Sub-Total)
Civ. C.)
PLAN CHECKING FEE =:r°z .
Lender's Name
PERMIT ISSUING FEE = "n •f
Lender's Address
I certify that I have read this application and under penalty of puriury state TOTAL FEE 3U z
that the 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 pu oses. 1_0SEE REVERSE FOR EXPLANATORY LANGUAGE
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