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DBS.5A 355 APPLICATION FOR ELECTRIC PERMIT
DB S.S
DIVISION OF BUILDING AND SAFETY
Department of County Engineer
County Of Los Angeles
WM.J. FOX. COUNTY ENGINEER �+DD RE55✓ ( PJ
CASSATT D.GRIFFIN, SUPT OF BUILDING [ ,
LOCALITY
FOR APPLICANT TO FILL IN
PERMIT FEES NEAREST CROSS ST. W a�
NUMBER EACH FEE m, n C
LIGHTOUTLETS 11 OWNER /`_ Y!//
l/� MAIL
RECEPTACLES '4 ADORESS
WALL SWITCHES n
TOTAL OUTLETS 5C S CITY TEL.NO ]�- '
ELEC. RANGES 25 ELECTRICIANf�ELEC. HEATERS 25 ADDRESS. .aKWEA CITY TEL.NO.
FIXTURES V' 5 S'1 LICENSE NO.
11 A4 NUMBER OF LIGHT C IRCUITS - DISTRICYNO. (GROUP 7,QNE I READY FOR INSPECTION
NUMBER OF RECEPTACLE CIRCUITS II I�T]J
MOTORS
NUMBER HORSEPOWERFEE INSPECTION RECORD
NEW I MVO. HP OVER I INC. EACH
1/$@ LESS S .25
/2 2 .50
2 5 1.00 _
5 IS 1.50
_ 15 50 2.50
50 200 5.00
MISC.
NO.SIGNS NO.TRANS:
NO. SIGNS NO.LAMPS
FOR EACH PERMIT:
WIRING 31.00 ♦ V G
FIXTURES 51.00 ! Gb
SUPPLEMENTARY .501
jf APPROVALS
TOTAL FEE S DATE INSPECTOR'S SIGNATURE
1 HEREBY ACKNOWLEDGE THAT '1 HAVE READ THIS APPLICATION CONDUIT
ANO STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY AA
WITH ALC COUNTY ORDINANCES AND STATE LAWS REGULATING WIRING
ELECTRICAL WIRING,
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR FIXTURES n
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF
CALIFORNIA OR THAT I AM THE L INNER OF THE ABOVE POWER
DESCRIBED RESIDENT( P
SIGNATURE UTILITY CO.NOTIFIED �Arr
OF PERMITT
WILLIAM J. FOX, COUNTY ENGINEER VALIDATION A. C.VEIT.CHIEF ELECT. INSPECTOR
IAGO0 3'0-5, SEP18 2 2.40
�,/ U
1 WOIT.(ERS'�CMPENSATION DECLARATION 76A663 I0/8I APPLICATION
l� n p g N �[ I� PERMIT
I hereby affirm 'tiat 11 have o certificate of consent to self CE-8066 YYIr�IL��P9110®PCI Ir®II•t ELECTRICAL IL-��YN60�
insure, ar o certificate of Worker' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY I`fl
or a certified copy thereof (Sec. 3800, Lab. C.) '
Policy No. _112_-_f Company FOR APPLICANT TO FILL IN- JOB r
Certified copy is hereby furnished. New Residentiol Bldgs. 8 Pools EACH NO. FEE ADDRESS
❑ Certified copy is filed with the county building inspec. 18 2-Fomily, Sq. Ft. $ — $ LOCALITY
tion department. Multi-family Sq. Ft. — NEAREST
CROSS ST.
/��(_ Residential Swimming Pools OWNERO
Date `_ v Applicant OWNER OR
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORK RS' ) l 5 _ MAIL
Outlets: Rec_Light�$w.
COMPENSATION INSURANCE First 20 �. O ADDRESS
(This section need not be completed if the work involved by Total No. 7-o Additional CITY Tel. No.
the permit is for one hundred dollars ($100)or less.)
I certifythat in the performance of the work for which this PLAN CHECK
P APPLICANT
permit is issued, shall not employ any person in any manner
so as to become subject to the Workers'Compensation laws. Lighting Fixtures First 20 ADDRESS
Total No. Additional
CITY Tel. No.
pplicanl Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, after makin "cote of Range— Heater—D.W.W. APPLICANT
Exemption, you should be lect to the Workers' 9
Compensation provisions of the Labor Code, you must forth. Oven — Dryer — W.M.— ADDRESS
with comply with.such provisions or this permit shall be Top FAU —W.H. —
deemed revoked. Hood Fan _Other_ CITY q Tel. No.
LICENSED CONTRACTORS DECLARATION LICENSE OR
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. Room Air Cond. REG. NUMBER 2 9Z Class.
(commencing with Section 7000) of Division 3 of the Business Power Apparatus 8 Large Appliances DISTRICT NO. PROCE$ E BY d'
and Professions Code, and my license is in full force and effect. i1C/ 0
Size 8 Type HP, KW; KVA, or KVAR'
GIN 0
License Number''C�711 L!g I Z tic. Class Up to 1 Inc. FINAL 0:
3 Over 1 to 10 incl. DATE / VAL ATION
ContraUor.f4 0
.lGLelDate r0 Over 10 to 50 Incl. FINAL !! W
am exempt u er Over 50 to 100 Inc. BY N
B.BP.C. for this reason Over 100 Z
Date: Services, Swbd., MCC 8 Panelboards ' D
0 - 200 Amp. Under 600 V R421.5A
Signature 201 - 1000 Amp. Under 600 V
❑ Over 1000 Amp. or Over 600 V -#.e o 0,0 o '2
� Exemption for Reg. Maint. Elect. �( -.- 44,50
SINGLE FAMILY Temp. Power Pole 8 Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit `o e o 4 Q 5 0
I hereby affirm that I am exempt from the Contractor's License Additional Sign Branch Circuits
Law for the following reason (Section 7031.5, Business and312-86
Professions Code):
❑ 1, as owner of the property, will do the work and the Misc. Conduits 8 Conductors
structure is not intended or offered for sale (Section Other (See.Complete Fee Schedule)_ D
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)
(Sec. 3097, Civ. C.).
Lender's Name PLAN CHECKING FEE
' 'O '
PERMIT ISSUING FEE (J w
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 Stole laws regulating Electrical wiring, and
hereby clitrintrize representatives of this County to enter upon
the ob e e boned per r inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
VIA—
Signature of Permittee a
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