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COUNTY of Los ANGELES - 'APPLICATION FOR PERMIT
' - DEPARTMENT OF COUNTY ENGINEER ELECTRIC 1
DIVISION OF BUILDING & SAFETY
WILLIAM 1. FOX, COUNTY ENGINEER
FOR APPLICANT TO FILL IN DISTRICT NO ` GROUP ZONE PERMIT NO
rrJ 1 I c /� 1,
" Ejf RECEIVED BY READY FOR DATE ISSUED
ADDRESS
�p FIRST INSPECTION
CITY ✓ L.j ,rF �,CJ• / fi' �i"- I r��
„ �.!' [f • i3� g/ ITEL NO U {�I��.3Y'l�iyF
COUNTY LICENSE NO r ! EXPIRES `+1 BUILDING /�dy r
PEE;MIT FEES ADDRESS ✓ J� '�� r Y"Yf dT !�#
y
FEE
NUMBER EACH Ir f /'/I� C�� ���,,,
LOCALITY <�c'h'i✓�.i �.-•I "'
LIGHT OUTLETS �/ / ,�fri j/ ,r
F NEAREST
RECEPTACLES OSS T .• / +f ,� �,,,.[!.,rt VV J
WALL SWITCHES OWNER ��/ �`I ✓�l.�C/'"f! t "` � .f''
TOTAL OUTLETS %�a 5c $ 12 ,'I -
py Z' r MAIL
ELEC RANGES 25 ADDRESS r f
ELEC HEATERS 25 pJ{ j
FIXTURES
!r CITY lLir f. r� /r TEL NO
i Jf 5 ��.�) - _
MISC 1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS
NUMBER OF LIGHT CIRCUITS APPLICATION AND STATE THAT THE ABOVE IS CORRECT
AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES
NUMBER OF RECEPTACLE CIRCUITS AND STATE LAWS REGULATING ELECTRICAL WIRING
7 MOTORS 1 CERTIFY THAT 1 POSSESS THE ABOVE VALID LOS
NUMBER HORSEPOWER FEE ANGELES COUNTY LICENSE, OR_I,AM THE LEGAL OWNER
NEw MVD HP OVER INC EACH ,,rye OF THE RESIDENTIAL PSR/O//PEATY DESCRIBED ABOVE
'/z a LESS $ 25 -.Y SIGNATURE OF v1
'/x 2 50 PERMITTE r`6
2 5 1 00 INSPECTION RECORD
5 15 1 50
15 50 2 50
50 200 5 00
200 500 10 00 .J
500 1000 is 00 a
'Z
OVER 1000 20 00
M G SET/FREQ CHANGER-HP
WELDERS AC-KVA 0
GENERATORS KW
TRANSFORMERS-KVA r -
TEMP MOTORS (75% OF ORIG ) 1
MOVED MOTORS (75% OF ORIG ) "'
MISC
SIGNS
NO NO TRANS
NO NO LAMPS APPROVALS
FOR EACH PERMIT 7 DATE INSPECTOR'S NAME
WIRING $1 00 V .+^'" CONDUIT /
FIXTURES $1 00
WIRING
SUPPLEMENTARY 50 FIXTURES 1,I, i pA �,(��i/�
POWER n h i7 I fLo 7 f�
TOTAL FEE $ `� UTILITY CO NOTIFIED ,!' !1t 11/19/ah7�� 0
INA g�v� ✓
76A 668 DBS# BA 4-BA 11 11 v I
WORKERS'COMPENSA�iON DECLARATION 63
` CE CE 806G (2 80) APPLICATION FOR ELECTRICAL PERMIT
8
I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY
insure, or a certificate of Workers'Compensation Insurance,or /
a certified copy thereof(Sec 3800,Lab C)
FOR APPLICANT TO FILL IN JOB O
Policy No ADDRESS Company EACH NO FEE
_ New Residential Bldgs &Pools _
ql
Certified copy is hereby furnished 1 &2-Family,Sq Ft $ — $ LOCALITY
❑ Multi family Sq Ft NEAREST ti
Certified copy is Bled with the county building inspection CROSS ST
department J ////y�y/�/1 Residential Swimming Pools OWNER OR
Date �I �A hcant y6 l FIRM NAME
pp d (Outlets Rec Light Sw �U MAIL
First 2—O— ADDRESS
CERTIFICATE OF EXEMPTION FROM WORKERS' Total No e2- Additional CITY Tel No
>_COMPENSATION INSURANCE PLAN CHECK 0-
APPLICANT
-(This section need not be completed if the work involved 0
by the, permit is for one hundred dollars ($100) or less) Lighting Fixtures First 20 ADDRESS
Total No Additional O
I certify that in the performance of the work for which thisCITY Tel No 1-_
permit Not Over 1 HP
permit is issued, I shall not employ any person in any manner , PERMIT Q U -
so as to become subject to the Worker ' m ensation aws Range_ Heater_D W APPLICANT v .0 a
Oven _ Dryer_W M ADDRESS r N
Applicant Top — AU _W H z
Hood _ Fan —Other CITY el No
OTICE TO APPLICANT If, after making this Certificate of Disp _ Room Air Cond .�.SU .,1 ,SQ LICEN R /O
Exemption, you should become subject to the Workers' REG NUMBER Class
Compensation provisions of the Labor Code, you must forth Power Apparatus& Large Appliances DISTRICT NO PROCE EDB
with comply with such provisions or this permit shall be
deemed revoked Size&Type HP, KW KVA or KVAR
Up to 1 Incl FINAL
Over 1 to 10 Incl
LICENSED CONTRACTORS DECLARATION Over 10 to 50 Incl DATE VALIDATION
I hereby affirm that I am licensed under provisions of Chapter J Over 50 to 100 Inc FINAL-
9 r1
(commencing with Section 7000) of Division 3 of the Busi Over 100
ness and Pro fessions"Code, and my license is in-full force and- - _= - BY
effect Services
=.6tate
0-200 Amp Under 600 VLicense NumbeLic Class 201 1000 Amp Under 600 V
Contractor_420 Over 1000 Amp or Over 600 V
HOME OWNER BUILDER DECLARATION Temp Power Pole&Appurtenances
I hereby affirm that I am exempt from the `Contractor's Sign with One Branch Circuit
License Law for the following reason (Section 7031 5, Busi Additional Sign Branch Circuits
ness and Professions Code) -
Misc Conduits&Conductors 21 3 6 4 A
El I, as owner of the property, will do the work and the Other (See Complete Fee Schedule)—
structure is not intended or offered for sale (Section # 0 0 0 0 o 2
7044, Business and Professions Code)
CONSTRUCTION LENDING AGENCY , ` 2 0 f02 3,0 0
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is PERMIT FEE - (Sub Total) / 0 0 0 2 3,0 005
issued (Sec 3097,Civ C) �O -
Lender's Name PLAN CHECKING FEE (One Fourth Permit Fee) 0 9,29-81
Lender's Address
PERMIT ISSUING FEE-
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
hereb aut or a representativesof this County to enter upon
the ov a ed pro rty for inspection purposes y
mSEE REVERSE FOR EXPLANATORY LANGUAGE
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Sig ature of Permittee Date v