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76AG63-CHOOS 3-39 APPLICATION FOR ELECTRIC PERMIT 1
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER BUILDING
BUILDING AND SAFETY DIVISION ADDRESS .,0 3 i A
JOHN A. LAMBIE, COUNTY ENGINEER - p (/� /
CASSATT D. GRIFFIN,SUPT OF BUILDING LOCALITY TF-m �LE �+i T'
FOR APPLICANT TO FILL IN NEAREST
PERMT FEES cRoss sr.
OWNER S Ilf
1 T E M NUMBER I EACH FEE
OUTLETS: $ $ MAIL
LIGHTS RECEPT SW. 10 o ADDRESS
LIGHTING FIXTURES 10 Zo CITY `L
TEL.NO.
ELEC.RANGES cLO�RY�Rs /) ELECTRICIAN p `I
WATER HEATERS 1 .50 �� ADDRESS y1. ,/�/
ELEC.SPACE HTRS. DISHWASHERS CITY i7 IV 1517-6TEL. NO.
GARBAGE DISPOSERS AUTO.- STATE
S
WASHERSTA.COOKING UNITS `5 .25 / J LICENSE NO.
MOTORS: OVER INC. H.P. ac
DISTqj�--TI ZO
G P NE I PR CESSED BY
0— 1/2 .25 `& ,QN
1/2— 2 .50 INSPECTION RECORD
2— 5 1.00 0
5— 15 1.50 �� cv
is— 50 2.50 r
SO—200 5.00
SIGNS: NO.TRANS.
NO.LAMPS
SERVICE 0-600V 1.00.
SERVICE OVER 600V 5.00
MISC.
WIRING PERMIT 1.00 f 0
FIXTURE PERMIT 1.00
eQ
SUPPLEMENTARY PERMIT .50
TOTAL FEE $
I 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, % WIRING tp (Ao
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF FIXTURES
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVEDESCRIBED s
ESIDENTI P OPERTY./I UTILITY Y CO.NOTFIED
AAAAVVVV/IIIII/V t
OF PERMITTE
•, FINAL
�p VA DATIONARTHUR C.VEIT,
MO CASH SUPERVISING ELECTRICAL ENGINEER
CK
L�I",,,g 0 1 1 JUN 3 0 2 A 12 .4 5
'+� WORKERS'•COM?'ENSATION DECLARATION CEA806G 10/81 APPUCATON FOR ELECTRICAL PERMIT
• I elereby affirm that I have a certificate of consent to self insure,
or a certificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy, thereof'(Sec.3800,Lab. C.) 'fl
Police No. Company FOR APPLICANT TO FILL IN JOB �t�
❑ Certified copy is hereby furnished. New Residential Bldgs.& Pools EACH NO. FEE ADDRESS Q / r,4 �t
❑ 1 & 2-Family,Sq.Ft. $ — $
Certified coLOCALITY '"��� L f
copy is filed with the county building inspection NEAREST
department. Multi-family Sq.Ft.
CROSS ST. /QOS
Date Applicant Residential Swimming Pools OWNER OR �o
, /n� FIRM NAME. (f /V y/A/&- NOW f�
CERTIFICATE OF EXEMPTION FROM WORKERS' Light MAIL
Outlets:Rec Sw.
COMPENSATION INSURANCE /7P d4 ADDRESS �MZ-
(This section need not be completed if the work involved by the First 20
permit is for one hundred dollars($100)or less.)
Total No. Additional 1 CITY Tel.N .
I certify that in the performance of the work for which this permit PLAN CHECK
an
is issued, I shall not employAPPLICANT
y person in any manner so as to ,
become subject to the Workers'Compensation Laws. Lighting Fixtures First 20ADDRESS
727
Total No. 14 Additional
CITY Tel.No.
Date Applicant Fixed Appliances Not Over 1 HP PERMIT �o
NOTICE TO APPLICANT: .If, after making this Certificate of APPLICANT G ✓/V�j y/� /V (�
Exemption,you should become subject to the Workers'Compensation Range_ Heater_ D.W.
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 CITY Tel.No.
I herebyaffirm that I am licensed under Other_
provisions of.Chapter 9 LICENSE OR
Disp. - Room Air Cond. REG.NUMBER Class.
(commencing with Section 7000) of Division 3 of the Business and
Professions Code,and my license is in full force and effect. Power Apparatus& Large Appliances DISTRICT NO. PR CE ED BY
Size& Type HP,KW,KVA,or KVAR
License Number Lic.Class Up to 1 Incl. FINAL U
Over 1 to 10 Incl. DATE r/y� Z VALIDATION 0
❑
Contractor Date Over 10 to 50 Incl. r FINAL
I am exempt under Sec. Over 50 to 100 Inc. BY W
B.&P.C. for this reason Over 100 N'
Services(- MCC& Panelboards o ® ''
Date: 0 2 mp.Under 600 V
Signature 201 - 00 Amp.Under 600 V
Over 1000 Amp. or Over 600 V
Exemption for Reg.Maint.Elect.
SINGLE FAMILY Temp.Power Pole& Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit - •3 - -• <r
I hereby affirm that I am exempt from the Contractor's License Law C. ;y= a-p, ;,y ,
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits _
Code): _ t a...
Misc. Conduits& Conductors
I,as owner of the property,will do the work and the structure j = •`�`-
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) ,
and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the rt+ ANJ4
performance of the work for which this permit is issued(Sec.3097, PERMIT FEE (Sub-Total) = �i_ t• :Fit
Civ.C.).
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE,
Lender's Address
I 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
proper or inspec n purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature o .Permittee Date