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76AG63-CE606 9-66 APPLICATION FOR ELECTRICAL PERMO T
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER BUILDINGr''1
6
BUILDING AND SAFETY DIVISION AOOREss /o cj:vFt
JOHN A. LAMBIE, COUNTY ENGINEER
COLEMAN W. JENKINS, SUPERINTENDENT OF BUILDING LOCALITY I F1")'Afr n 7y
NEAREST -1
FOR APPLICANT TO FILL IN CROSS ST.
RECEPT. TOTAL NO. IEACH I FEE
1 OUTLETS FIRST 20 15.20 $ OWNER 'TO/�itl /A/'lS
LIGHT MAIL
SWITCH ADD
'L 10 ADDRESS
OVER 20 �v /cam/
TOTAL FIRST 201 .20 CITY / 1,/ •TEL. NO, -f0/,J n
LIGHTING FIXTURES �r�,�
FIXTURES ADD'L 10 CONTRACTOR dAe / ,
OVER 20_
RANGES DRYERS WTR.HTRS. 1.00 ADDRESS
GARS.OISP. STA.COOK
CITY TEL.'ND. F9 il9.O
DISHwASH. AUTO.-WASH. STATE
SPADE HTRS. BTA. APPL. .50 LICENSE NO. _
MOTORS: OVER NOT OVER H.P. DISTRICT NO. G P I PIN E I PR SED BY
O 1 1.00 / I w _ Q
1 — 3 1.So1 INSPECTION RECORD
3 — e 12.00
B 1s __12.501
15 50 13.00 d
so 100 15.00 1 O
SIGNS: NO.TRANS�
NO. LAMPS O
F-
SERVICE O.600V-NOT OVER 200A 1.00
SERVICE 0.60OV.OVER 200 A. 12.00
z
SERVICE OVER 600V 15.00 /
OTHER (SEE COMPLETE FEE SCHEOULE)
I
PERMIT ISSUING FEE 12.00 (/
SUPPLEMENTARY PERMIT ISSUING FEE 1.00 APPROVALS DATE INSPECTOR-5 SIGNATURE
TOTAL FEE 0
I 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
ELECTRICAL WIRING. WIRING P M
1HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR FIXTURES
LICENSED AS REQUIRED BY LOS ANGELES COUNTY NO STATE OF
CALIFOfl NIA OR THAT I A THE OWNER OF, D INTEND TO POWER
RESI DE IN,THE ABOV E RI 1D AL PERTY.
61GNATU RE UTILITY CO.NOTIFIED
OF PERMITTE
FINAL
/Y.p,LIDATION JOSEPH C. ROOHAN
SUPERVISING ELECTRICAL ENGINEER
CK MO CASH
LACo " 1 6 4G APR 21 2 D 3.80" s
J. r ✓
D5"863APPLICATIONFOR L-LECTRIC PERMIT qI1
"'-5A12.56 I1
DIVISION OF BUILDING AND SAFETY dY
Deportment of County Engineer - - -
CountyFO o1 Los Angels.
`BUILDING
WM. J. FOXCOUNTY ENGINEER
ADDRESS lJ / /GO G[iK6�r-GC
' CASSATT D. GRIFFIN. SUPT of BUIL O1NG
FOR APPLICANT TO FILL.IN LOCALITY
PERMIT FEES CROSS ST. � .
NUMBER EACH FEE I 1
LIGHT OUTLETS OWNER
RECEPTACLES MAIL
AODRESV
WALL SWITCHES _
TOTAL OUTLETS Sd S CITY -TELL/NO.
1 ELEC. RANGES 5 _�� ` ELECTRICIAN y2(
'ELEC. HEATERS
ADDREBB � �
KW EA
- CITY \ TEL. NO.
FIXTURES 5 LICENSE NO.
NUMBER OF LIGHT'CIRCUITS
DISTRICT NO. ' �GROUP ZjQNE aEnor FOR INsvEcn on
NUMBER OF RECEPTACLE CIRCUITS 3
MOTORS
NUMBER HORSEPOWER FEE. INSPECTION RECORD
NEW MVO. HP OVER INC. EAG.
_ Ih @ LESS $ .25
V2 2 .50
_-_ 2 5 1.00 '
_ 5 15 1.50 _
15 50 2.50 '
50 200 5.00
MISC.
NO. SIGNS NO. TRANS. -
NO. SIGNS NO. LAMPS _
FOR EACH PERMIT:
WIRING $1.00 U�
FIXTURES
SUPPLEMENTARY ..50 __
l APPROVALS
TOTAL FEE $ l `� DATE INSPECTORS SIGNATURE
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CONDUIT
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE. LAWS REGULATING WIRING
ELECTRICAL WIRING. .
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR FIXTURES
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF POWER 1
CALIFORNIA OR THAT I M THE EGA NER OF THE ABOVE
DESCRIBED RESIDENTIA E
UTILITY CO. NOTIFIED
SIGNATURE _
OFPERMIT FINAL N
WILLIAM J. FOX,COUNTY.ENGINEERT . ,J T%i i y_''�': 1 2 . 125'.
@
MY
O DEPUTY
WORKERS'COMPENSATIONDECLARATION 78-663 10/e1
CE-Bost APPLICATION FORELECTRICAL PERMIT {�
I her affirm that I have a certificate of consent to ?.If 'insure, COUNTY OF LOS ANGELES BUILDING AND SAFETY
LJ
or a certificate of Workers' Compensation Insurance, or a certified
t
copy them (Sec.3'65PJ`1.xb.C.) ,
Polieyt}Jo. Iyvr' Company /F��/ ..�1- _ FOR APPLICANT TO FILL IN "' JOB
❑ - r>,.� EACH NO. FEE ADDRESS
Certified copy is hereby furnished. New Residential Blc•3s.8 Pools LOCALITY
Ia' Certified copy is,filed With the county building inspection 1 & 2-Family,Sq.Ft. $ _ $ -
•department - Multi-family Sq.Ft.. NEAREST
/ 9 t 71 CROSS ST.
Date ^` ^v�Applicam ,,, > / '/ Residential Swimming Pools OWNER
_ FIRM
-• CERTIFICATE OF EXEMPTION FROM WORKERS' � MAIL t
COMPENSATION INSURANCE Outlets:Rec—light Sw. — /' ADDRESS ^
(This section need not be completed If the work involved by the First 20 r
Total No. Additional • _ CITY Tel.No,
permit is for one hundred dollars($100) or less.) f *' 5, PLAN CHECK '
I certify that in the performance of the work for which this permit -' APPLICANT
is issued, I shall not employ any person in any manner so as to
become subject to the Workers'Ccmpensation Laws. Lighting Fixtures First 20 ADDRESS • -
Additional _
Total No. - CITY Tel.No.
Date Applicant - Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO, APPLICANT: If, after, making this- Certificate of S(,tr/1//q Z2 � G.
Exemption,you should become subjecttto the Workers'Compensation Range_ Heater_ D .
APPLICANT /
provisions of the Labor Cade, 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_ f - -
.I hereby affirm that I am licensed under provisions of Chapter 9 Dis p. — Room Air Cond. _ LICENSE S Class.
'(commencing with Section 7000) of Division 3 of the Business and REG.NUMBER �I.S
Professions Code,and my license is in full force and effect.• Power Apparatus& Large Appliances DISTRICT NO. P 0 BRED BY
_
Z//_�� � f/�L.LG�c/
Size&Type HP,KIN,KVA,or KVAR U
License Numbeie.Class C--/" W ��
Up 1 Incl. FINAL' d -
/ Over 1 to 10 Incl. 1_1 VALIDATION H O
Contractor LIZ Dat _-" •� - - DATE
Over 10 to 50 Ind. FINAL n (,)
❑ I am exempt under Sec. - . . Over 100 Inc. BY N
B&P.C. for this reason 100 AA/GGG
S In CC&Parmboards '
Date: 0 mp. der 600 V
Signature 201 - p.Under 600 V
Over 1000 Amp.or Over 600 V
❑ Exemption for Reg.Maint.Elect. - - - _ ')
'- -SINGLE FAMILY - Temp.Power Pole& Appurtenances •• a r
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit At�`CT•t
I hereby affirm that I am exempt from the Contractor's '0
s License Law Additional Sign Branch Circuits,.- - 7303 75.60
for the following reason(Section 7031.5, Business and Professions _ -
Code): 1 ITEMS
❑ I,as owner of the property,will do the work and the structure Misc.Conduits 8 Conductors
p y, TOTAL 75 60
•is not intended or offered for sale (Section 7044, Business Other (See Complete Fee Schedule) D ,
and Professions Code). •" / - - CASH 75.60
CONSTRUCTION LENDING AGENCY 5,.,",g- r - - CHANGE - • -- •00
I hereby affirm that there is a construction lending agency for the.
performance of the work for which this permit is issued(Sec.3097, PERMIT FEE (Sub-Totap
Civ. C.). GOOD—OOD1 1/ 9/96
PLAN CHECKING FEE .- - -
Lender's Name 4178 1. AM11:52
PERMIT ISSUING FEE,
Lender's Address
certily that ve read this application and state that the above TOTAL FEE •7 F�
inforn(ation is._ rract. I agree to comply with all County ordinances.
and State s regulating Electrical firing, and hereby authorize ,
represent es of this Corm to r upon the above-me one
mperl o in
pspection C m as. G SEE REVERSE FOR EXPLANATORY LANGUAGE '
Signature of Permittee Da[