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DEIS65A 1254 4 O1E ��'M/-1���Y9 Y �Y ■ ��i���Y ■�V �Ya �YV� � 1
DIVISION OF BUILDING AND SAFETY
Department of County Engmeer
County of LOS Angeles BUILDING 1
WM J FOX, COUNTY ENGINEER ADDRESS s
CASSATT D GRIFFIN, SUPT OF BUILDING N,
i
FOR APPLICANT TO FILL IN, LOCALITY 01
PERMIT FEES NEAREST
CROSS ST
NUMBER EACH FEE P
LIGHT OUTLETS OWNER ,N a
RECEPTACLES MAIL
4DDR SS
WALL SWITCHES
TOTAL OUTLETS 50 S CITY EL NO
ELEC RANGES 25 ELECTRIC AN
ELEC HEATERS 25 ADDRES
KW EA CITY TEL NO
FIXTURES 5
LICENSE NO d
NUMBER OF LIGHT CIRCUITS DISTRICT NO GROUP ZONE I READY FOR INSPECTION
NUMBER OF RECEPTACLE CIRCUITS J
MOTORS
NUMBER HORSEPOWER FEE _ INSPECTION RECORD
NEW MVD HP OVER INC EACH '
_ i�&LESS S 25
I/2 2 50 �' f / �1
2 5 1 00 `/ G�Oma" Iv..Pp� �Q 1/1119, 7-'-k" AW-2
5 15 1 50 12-04 .4d /�!!�" 2-3ofl P1
I 15 50 2 50
I
50 200 500
MISC ,9 •/Q G
xl /� &-zJ Ki -117-4)
�N
�p/�,Mp �•�/`1lfF'/�
NO SIGNS NO TRANS -
NO SIGNS NO LAMPS
FOR EACH PERMITS
WIRING $100
FIXTURES S 1 00
SUPPLEMENTARY 50
j APPROVALS
TOTAL FEE S / DATE INSPECTOR SSIfGNATURE
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CONDUIT I n?-Wo" y f,!
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY I •�+^�
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING WIRING
ELECTRICAL WIRING
1HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR FIXTURES
LICENSED AS REQUIRED BY L S ANGELES COUNTY AND STATE OF POWER
CALIFORNIA OR THAT I A /THE LEG L' OW O HE ABOY,9 /
DESCRIBED RESIDE N /qq� P PERTY UTILITY CO NOTIFIED
SIGNATURE
OF PERMITTEE FINAL
WILLIAM J FOX, COUNTY ENGIN ER VALIDATION
v -
AC04Y2 3 2-S JUN -1 - 2 1 .25
EPUTY ti
WORKERS'COMPENSATION DECLARATION 76A663 10/81 APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that f'have a ; CE ertificate of consent to self CE 8o6G � r
insure, or a certificate-of Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified copy thereof (Sec 3800, Lobb C )
Policy No n @ Company SWI:E L°O �NS FOR APPLICANT TO FILL IN JOB'
fL��lL Certified copy is hereby furnished New Residential Bldgs & Pools EACH NO FEE ADDRESS 9,091 14514 a01f 10,94,46
—
Certified copy is filed with the county building inspec- 1 & 2-Family, Sq- Ft $ — $ LOCALITYN _L,
tion department Multi-family Sq Ft 'NEAREST
w,f CROSS ST �/ Q
Date AppIicant����/; Q/ 141
Residential Swimming Pools OWNER OR Q
r FIRM NAME /7
CERTIFICATE OF EXEMPTION FROM WORKERS' - Light Rec Light 5 Sw MAIL
COMPENSATION INSURANCE First 20 n(J ADDRESS
(This section need not be completed�f fhe work involved by Total No�� CITY Tel No
the permit is for one hundred dollars ($100)or less ) Additional, 3
I certifythat in the performance of the work for which this PLAN CHECK
P er _ 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
Date Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT If, afters making this Certificate of APPLICANT
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 w Top FAU _ _W H
deemed,revoked ~ CITY ./ — Tel No
Hood, _ Fan __LOther—
LICENSED CONTRACTORS DECLARATION LICENSE OR
I hereby affirm that,l am licensed under provisions of Chapter 9 Disp Room Air Cond REG NUMBER Class
(commencing with Section 7000) of Division 3 of the Business DISTRICT N _/ PROCE D BY
and Professions Code, and m license is in full force and effect Power Apparatus& Large Appliances (o/ >_
Size &Type HP, KW, KVA, or KVAR ` 0.O
License Number Lic Class 1 Up to 1 Incl FINAL - V
Over'l to 10 Incl DATE VA
IDATION 09
Contractor Date Over 10�to 50 Incl V
FINAL
I am exempt under Sec Over 50 to 100 Inc BY MA
B &P C for this reason Over 100 7 7 1
Date Se ry es, Swbd , MCC'& Panelboards /,
200 Amp Under 600 V (J # o
Signature 201 - 1000 Amp Urider 600 V
Over 1000 Amp or Over 600 V
Exemption for Reg Mamt Elect • 75
SINGLE FAMILY Temp Power Pole &Appurtenances _
1 HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit m e . 4 8,7 5 cz.
I hereby affirm that I am exempt from the Contractor's License Additional Sign Branch Circuits t
Low for the following reason (Section 7031 5, Business and Q &27 -87
PP fe sions Code)
I as owner of the property, will do the work and the Misc Conduits&Conductors
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ ,
7044, Business and Professions Code)
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) 7 8 Q 5 A
(Sec 3097, Civ C )
PLAN CHECKING FEE # o e o • o G
Lender's Name '
PERMIT ISSUING FEE E 1 • - 4875
Lender's,Address
I certify that I have read this application and state that the I TOTAL FEE • o o 4 8,7 5 v
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 G 3 — 7
the above-mentioned pro erty for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
S nature of Permit a Date