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COUNTY OF LOS ANGELES LL _ �L.,, _j;'..1.7 u..- -.
DEPARTMENT OF COUNTY ENGINEER BUILDING �j •/ t', / yy/Q��/� dii/
BUILDING AND SAFETY DIVISION ADDRESS J �j .(� 1 Li f?"V
JOHN A. LAMBIE,.COUNTY ENGINEER G�71,,, �� �i•j
COLEMAN W. JENKINS, SUPERINTENDENT OF BUILDING _LOCALITY 7- T
NEAREST
FOR APPLICANT TO FILL IN CROSS ST. p �L�S
RECEPT• 1 TOTAL NO. EACH FEE
OUTLETS LIGHTFIRST 20 $,20 $ OWNER
SWITCH J} ADD'L 1O ADDRESS
VER 20
FIXTURES 2
TOTAL O RST 0 .20 CITY /� ��, TEL. NO."77 �`S��3
LIGHTING -1
FIXTURES ))(( ADD'L1O CONTRACTOR
OVER 20
RANGES DRYERS WTR.HTRS. 1.00 ADDRESS
GARB.DISP. STA.COOK.
CITY TEL. NO.
DISHWASH. AUTO.-WASH. STATE
9l
SPACE HTRS. STA. APDL. .50 LICENSE NO.
MEF
MOTORS: OVER NOT OVER H.P. •DISTRICT .GR USP ZO E� PR ED BY
"nLoA Ceo 1 1.00 ' 'J
1 3 1.50 INSPECTION RECOR
3 S 2.00
8 15 2.50
15 50 3.00 '•' �"
Ji 0.
50 100 5.00
SIGNS: NO.TRANS Im
NO.LAMPS O
t 1—
SERVICE 0.60OV-NoT OVER 200A 1.00 yVj
C.
SERVICE 0-60OV-OVER 200 A. 2.00 U)
SERVICE OVER 600V 5.00
OTHER (SEE COMPLETE FEE SCHEDULE)
PERMIT ISSUING FEE 2.00 00
SUPPLEMENTARY PERMIT ISSUING FEE 1.00 APPROVALS DATE INSPECTOR'S SIGNATURE
TOTAL FEE Q
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION UNDERSLAB WORK
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY ROUGH CONDUIT
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING y
ELECTRICAL WIRING. • WIRING
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR FIXTURES V
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF
CALIFORNIA OR THAT I A THE LEGAL OWNER OF,AND INTEND TO POWER II
RESIDE IN,THE ABOV�FID CRIBED RES DETIAL rROPERTY
SIGNATURE ( �G/¢ UTILITY CO.NOTIFIED
OF PERMITTE
FINAL 3® " O
LIDATION JOSEPH C. ROOHAN
MO CASH SUPERVISING ELECTRICAL ENGINEER
WORKERS'COMPENSATION DECLARATION ,76A6 t9 DPW 3ie7 APF U CLAM N FOR C�d ECS M ICA d P E RN T
I hereby'affirm that I have a certificate of consent to self `Ce eoeG
insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
or a certified copy thereof (Sec. 3800, Lab. C.) '
Policy No. Company FOR APPLICANT TO FILL IN JOB❑ �j�i /(� y Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADDRESS 7 / �j
LOCALITY
Certified copy is filed with the county building inspec- 1 &2-Family, Sq. F.t. $ — $ - n'
tion department. Multi-family Sq. Ft. — NEAREST
C CROSS ST..
Date — � !' '7� - Residential Swimming Pools
J /Yl7 31 OWNER OR
Applicant j�'"
CERTIFICATE OF EXEMPTION FROM WORKERS' / Outlets: Rec� ���j / J FIRM NAME G 10c L /1 hn
Light /�/Sw. i.` C` MAIL
COMPENSATION INSURANCE ADDRESS' _S14�'i-
First 20
(This section need not be completed if the work involved by Total No. 30 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. Lighting Fixtures First 20 1 ADDRESS
Additional
Total No.Z� rl CITY Tel. No.
Date Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, after making this Certificate of APPLICATION
Exemption, you should become subject to the Workers' Range— Heater—.D.W. —
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 —W.H. —
deemed revoked. CITY .,71_�_ P r T. No.
LICENSED CONTRACTORS DECLARATION Hood — Fan —Other—
Dis — Room Air Cond. LICENSE M /
I hereby affirm that:l am licensed under provisions of Chapter 9 p• REG. NUMBER 1fY U Class.
(commencing with Section 7000)of Division 3 of the Business Power Apparatus& Large Appliances DISTRICPROCESSED T N SED BY >_
,
and Professions Code,and my license is in full force and effect. Type ®u O
J`6 �� r Size &T e HP, KW, KVA, or KVAR ((//
License Number Lic. Class Up to 1'Incl. FINAL ✓ U
/� G c' Over 1 to 10 Incl. DATE ✓ 01
Contractor �efi l /11�� �fiQ�Date n�4 f ALIDATIOM
❑ Over 10 to 50 Incl. FINAL 4 1--
I
I am exempt under Sec. Over 50 to 100 Inc. BY W
B.&P.C. for this reason Over 100 Y CL
p Servi bd., MCC& P nelboar µt D Z
200 Under V
Signature 201 - 1000 Amp. Under 6001/
❑ Over 600 V
Exemption for Reg. Maint. Elect. Over 1000 Amp. or� r
SINGLE FAMILY Tem Power Pole&Appurtenances L
HOME OWNER-BUILDER DECLARATION p' PP r• S
I hereby.affirm that I am exempt from the Contractor's License
Sign with One Branch Circuit A C a9'
Law for the'following reason (Section 7031.5, Business and Additional Sign Branch Circuits' ��17 61,11!1
Professions Code): 1
ITEMS
❑'I, as.owner of the property, will do the work and the Misc.'Conduits&Conductors
structure is not intended or offered for sale(Section•7044, Other (See Complete.Fee Schedule)— TOTAL 61® 00
Business and Professions Code). D (HECK 61.00
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for CHANGE- ,DO
the performance of the work for which this permit is issued PERMIT FEE (Sub-Total)
(Sec. 3097, Civ. C.).
PLAN CHECKING FEE1 1;131 —01301 11 3,0`85'
Lender's Name
PERMIT ISSUING FEE 7157 1 AM 8:4'2
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
Aaebove-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
ture of Per ittee ate OO s