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76weea ceeoe a eo A P P L.I C A T I O FOR EL C T R I C PERMIT 1
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEERBUILDING
BUILDING AND SAFETY DIVISION ADDRESS 5116 FARGO
JOHN A LAMBIE COUNTY ENGINEER
CASSATT D GRIFFIN SUPT of BUILDING LOCALITY TEh1PLE CI TY
FOR APPLICANT TO FILL IN NEAREST
PERMIT FEES CROSS ST
1 T E M NUMBER I EACH FEE OWNER ANDREW GRADY
OUTLETS )) y $ $ MAIL
LIGHTS RECEPT // SW [ 10 3 /O ADDRESS
LIGHTING FIXTURES I Q t0 t' Ov CITY TEL NO
ELEC RANGES CLO DRYERS ELECTRICIAN CHARLECIN Ff ' R I f I SIS
WATER HEATERS SO ADDRESS
(� 2O MISSION
ELEC SPACE HTRS DISHWASHERS CITY POMONA TEL NONA 96294
GARBAGE DISPOSERS AUTO STATE
QQ
..i fLIE NO 1 0188
WASHERS STA COOKING UNITS 2S y
MOTORS OVER INC H P Z�"I'I�I� I CjPE P a/ ED QY
0— +/2 25 dam/
1/2— z so PNSPECTION RECORD
2— S 100
� � � c� �a�sf-�,�► a� ,a.
S— 15 ISO
Is— 50 250
50-200 500
SIGNS NO TRANS P
NO LAMPS
SERVICE O 600V too
SERVICE OVER 600V Soo
MISC
WIRING PERMIT too ` 00
FIXTURE PERMIT 100 QQ
SUPPLEMENTARY PERMIT SO
TOTAL FEE $
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION APPROVALS DATE INSPECTOR S SIGNATURE
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING CONDUIT
ELECTRICAL WIRING ()
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR WIRING
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OFe
FIXTURES
CALIFORNIA OR THAT 1 ,4M THE LEGAL OWNER qFj THE ABOVE
DESCRIBED RESIDENTIA RO RTY POWER
SIGNATURE UTILITY CO NOTIFIED
OF PERMITTE
®P ATION ARTHUR C VEIT
C Mo CASH SUPERVISING ELECTRICAL ENGINEER
Lti o5 1 2 7 ' WG 17 2 0 7 95
WORKERS'COMPENSATION DECLARATION 76-663 70/$1 APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that 1 have a certificate of consent to self insure, CE-806G
or a certificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof(Sec.3800,Lab.C.)
.t
Policy No. Company FOR APPLICANT TO FILL IN JOB
❑ Certified co is hereby furnished. EACH NO. FEE ADDRESS
PY Y New Residential Bldgs. & Pools -i
F-1 — $
Certified copy is filed with the county building inspection 1 & 2-Family, Sq.Ft. $ LOCALITY
department.. Multi-family Sq.Ft. NEARESTCROSS ST.
Date Applicant
Residential Swimming Pools OWNER OR
FIRM NAME jr�j/GSC
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec Light — Sw. MAIL C
COMPENSATION INSURANCE ADDRESS
(This section need not be completed if the work involved by the First 20
Total No. Additional CITY Tel.No.
permit is for one hundred dollars ($100)or less.) ,
I certify that in the performance of the work for which this permit PLAN CHECK
is issued, I shall not employ any person in any manner so as to APPLICANT
become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS
Date Applicant
Total No. Additional
CITY Tel.No.NOTICE TO APPLICANT: If, after making. this Certificate of Fixed Appliances Not Over 1 HP PERMIT
Exemption,you should become subject to the Workers'Compensation Range_ Heater_ D.W. _ APPLICANT
provisions of the Labor Code, you must forthwith comply with such Oven _ Dryer _ W.M._ ADDRESS
provisions or this permit shall be deemed revoked. Top — FAU _ W.H.
LICENSED CONTRACTORS DECLARATION Hood — Fan Other_ CITY Tel.No.•
I hereby affirm that I am licensed under provisions of Chapter 9 LICENSE OR
(commencing with Section 7000) of Division 3 of the Business and Disp. — Room Air Cond. REG.NUMBER Class.
Professions Code,and my license is in full force and effect. Power Apparatus& Large Appliances DISTRI T O. R SED BY
Size & Type HP,KW,KVA, or KVAR
� 0
License Number Lic.Class Up to 1 Incl. 411NAL
NAL U
Over 1 to 10 Incl. AT W
Contractor Date VALIDATI N 0
❑ Over 10 to 50 Incl.
I am exempt under Sec. Over 50 to 100 Inc. BY W
B.&P.C.for this reason Over 100 N
Services, Swbd.,MCC& Panelboards Z
Date: 0- 200 mp. Under 600 V
Signature 201 - 1000 Amp.Under 600 V
❑ Exemption for Reg.Maint.Elect. Over 1000 Amp.or Over 600 V
SINGLE FAMILY Temp.Power Pole& Appurtenances
HOME OWNER-BUILDER DECLARATIONa
I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit AUT°$
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits 3307 2. t
Kl'�
T °•'�(1
as owner of the property,will do the work and the structure Misc.Conduits& Conductors 1 T
not intended or offered for sale (Section 7044, Business Other (See Complete Fee Schedule)
and Professions Code). CASH 25.50�"�® _��
� �` _
!
CONSTRUCTION LENDING AGENCY
1•�f` °
I hereby affirm that there is a construction lending agency for the C E °00
performance of the work for which this permit is issued(Sec.3097, PERMIT FEE (Sub-Total)
Civ.C.).
PLAN CHECKING FEE
Lender's
11/27/89Lender's Name
PERMIT ISSUING FEE 7010 • 1 AM11=14
Lender's Address
1 certify that I have read this application and state that the above TOTAL FEE
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 the above-mentioned
perty forMPM,
SEE REVERSE FOR EXPLANATORY LANGUAGE
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