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APPLICATION FOR ELECTRIC PERMIT
COUNTY OF LOS ANGELES - - -
DEPARTMENT OF COUNTY ENGINEER euaowc
BUILDING AND SAFETY DIVISION - aoDREss �/
JOHN A. LAMBIE. COUNTY ENGINEER
WILLIAM A.JENSEN.SUPT OF BUILDING LOCALITY
FOR APPLICANT TO FILL IN NEAREST
PERM FEES CROSS ST.
ITEM NUMBER OWNER EACH FEE
OUTLETS: 5 Y MAILCA A
LIGHTS RECEPT. SW. IO ADDRESS
LIGHTING FIXTURES 10 CITY Q. TEL.NO.
ELEC.RANGES CLO.DRYERS ELECTRICIAN
WATER HEATERS .SO ADDRESS L
ELEC,SPACE HTRS. DISHWASHERS
CITY TEL. NO.
GARBAGEDISPOSERS AUTO.- STATE
WASHERS STA.COOKING UNITS .25 1LICENSE NO.
MOTORS: OVER INC. H.P. DIST�[tICTN GROUPN R 6 DB
O— '/z .25 L� I I / Eby0
l_� 1i )
'/A- 2 •50 INSPECTION RECORD
2— 5 1.00
5— 15 1.50
Is— 50 2.50 /� -s ,./ p c1/y,./-•
50-200 5.00 ///-7• --/l/)'A/"i-) /YET J r//T/.C-D—
NO.TRANS. �• / YF/J A P4,ssiR1l1rY
SIGNS: NO,LAMPS
SERVICE O-600V 1.00
SERVICE OVER 600V 5.00
MISC.
WIRINGPERMIT 1.00 ��•/✓� F10MF•.l� /F /✓O 7-
FIXTURE PERMIT 1.00 /J `/z �1 r�� RY 1Y/'1/T P2J'/7-
SUPPLEMENTARY PERMIT 1 .50 `✓�L� �,�,
TOTAL FEE Is
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION APPROVALS DATE INSPECTOR'S SIGNATURE
ANO STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING CONDUIT
ELECTRICAL WIRING. WIRING
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR
LICENSED AS REOUIRED BY LOS ANGELES COUNTY AND STATE OF FIXTURES
CALIFORNIA OR THAT 1 AM THE LEGAL WNER OF THE ABOVE
DESCRIBED RESIDE AL PROPERTY. POWER
SIGNATURE UTILITY CO.NOT!FIED
OF PERMITT , .. FINAL .3" a--hl /�[� L✓OOO
®. VALIDATE ARTHUR C.VETT.
-� CK NO
GAB✓H SUPERVISING ELECTRICAL ENGINEER
WORKERS'COMPENSATION DECLARATION 76A663IO/BI
I hereby affirm that I have a certificate of consent to self CE-8066 APPLICATION
mPLICpTION FOR ELECTRICAL
Ef4ICpL PERMIT
insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified copy thereof (Sec 3800, Lab. C.)
Policy No. Company FOR APPLICANT TO FILL IN JOB Y
Certified copy is hereby furnished. New Residential Bldgs. 8 Pools EACH NO. FEE ADDRESS 15
Certified copy is filed with the county u Iding inspec- 1 8 2-Family, Sq. Ft. $ = E LOCALITY
114 e- Af 64
tlp,n departme Mulli-family Sq. Ft. NEAREST
r Residential Swimming Pools OWNER T. _
Date - 5—VY--Applicant
FIRM NAME
CERTIFICATE OF EXEMPTION FRO ORKERS' Outlets: Rec_Light_S,v._ 'MAIL
COMPENSATION INSURANCE ADDRESS
tThis section need not be completed if the work Involved b First 20 / �7
he permit is for one hundred dollars ($100)or less.) T Total No. Additional CI Tel. No load��
that in the performance of the work for which this PLA CHECK
I certify P APPLICANT
permit is issued, I shall employ any person in any manner -
so as to become subjectt to to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS
Total No. Additional
CITY Tel. No.
Date Applicant Fixed Appliances Not Over 1 HE PERMIT
NOTICE TO APPLICANT: If, after making this Certificate_of APPLICAN
Exemption, you should became subject to the Workers' Range— Heater—D.W.
Compensation provisions of the Labor Code, you must forth- Oven _ Dryer 7- W.
W.M.— ADDRESS Q/
with comply with such provisions or this permit shall be Top — FAU !W.H. —
deemed revoked. CITY
Hood Fan _ Tel N
_Other
LICENSED CONTRACTORS DECLARATION - LICENSEOR
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. REG. NUMBER Class. t
(commencing with Section 7000) of Division 3 of the Business - DISTRICT NO. PR SED BY
and Professions Code,and my license is in full force and effect. Power Apparatus 8darge Appliances
�( n /) Size 8 Type HP, KW, KVA, or KVARV
License Number-
r+ 1�---lla/e Lic. Classy 2��_ Up to 1 Incl. FINAL 7
��Icrmr�u /L�Date J ^iW(J Over 1 to 10 Incl. DATE VALIDATION p
Contractor Over 10 to 50 Incl. FINAL FV
I am exempt under Sec. Over 50 to 100 Inc. BY �,� � d
Over 100 Q118.8P.C. for This reason
Services, Swbcl MCC 8 Ponelboards D I Z
Date: 0 - 200 Amp. Under 600 V
Signature 201 - 1000 Amp. Under 600 V
❑ Exemption for Reg. Mains. Elect. Over 100 0 Amp. or Over 600 V
SINGLE FAMILY Tem Power Pole 8 Appurtenances
HOME OWNER-BUILDER DECLARATION P Ci 009 Z 6 A
Sign with One Branch Circuit
hereby affirm that I exempt from the Contractor's License Additional Sign Branch Circuits # o e,e e o '2
Law for the followingg r reason (Section 7031.5, Business and
Professions Code):
❑ e e
I, as owner of the property, will do the work and the Misc. Conduits 8 Conductors 2, I z 1'
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ f� 'e1 o a 2 1,0.0 66
7044, Business and Professions Code), IV,
CONSTRUCTION LENDING AGENCY 105,04-84
1 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, Cw.'C.).
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE
Lender's Address
I certify that I have ead this application and state fhol the TOTAL FEE
above information orrect. I agree to comply with all County
ordinan es and tat laws regulating Electrical wiring, and
here ufhori refire nlotwes of this County to enter pon
th v me tio� property for inspect n purpose . SEE REVERSE FOR EXPLANATORY LANGUAGE
ignature a Per iflee Date