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76A663-4r-E306 10.62 APPLICATION FOR ELECTRICAL PERMIT
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER _BUILDING
BUILDING AND SAFETY DIVISION ADDRESS
JOHN A. LAMBIE.•COUNTY ENGINEER
WILLIAM A.JENSEN, SUPT OF BUILDING LOCALITY '
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
RECEPT. TOTAL NO. EACH FEE
OUTS FIRST 20 $20 $ �T OWNER
LIGHT MAIL
SWITCH Aoo'L f0 ADDRESS,
'OVER 20
If
TOTA CITY TEL. N /
LIGHTING FIRST 20 .20 .�
FIXTURES ADD'L ELECTRI AN
OVER 20 -10
RANGES CLO.DRYERS WTR.HTRS. 1.00 ADDRESS
GARB.DISP. �• STA.COOK '
CITY TEL. N
DISHWASH.` WASHff4 STATE '�f -
SPACE HTRS. STA.APP.(% I"//.i H.P.MAX.) ,50 D LICENSE NO. (--
MOTORS:• OVER NOT OVER H.P. DISTRICT NO. GBOU ZONE P ESS D BY
�►^- i
O 1 1.00
1 3 1.50 INSPECTION RECORD
3 8 2.00 �-
- a
a is 2.50 O
V
15 50 3.00 oG
50 100 5.00 0
SIGNS: NO.TRANS. Y Q.
NO.LAMPS
h
z
SERVICE 0.000V-Nor OVER 200A 1.00
SERVICE 0.60OV-OVER 200 A. 2.00
SERVICE OVER 600V 5.00
MISC.
PERMIT ISSUING FEE 2.00
SUPPLEMENTARY PERMIT ISSUING FEE 1.00 `
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 CONDUIT
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING - ^ {� -
ELECTRICAL WIRING. WIRING - I L- ,� A�,p.�'v �., ,
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/•OR Q - -
LICENSED AS REQUIRED BY LOS ANG ES CO NTY A STATE OF FIXTURES
CALIFORNIA OR THAT AM THE L AL O E O THE ABOVE ,
DESCRIBED RESIDENT L PR ERTY. POWER
SIGNATURE UTILITY CO.NOTIFIED
OF PERMITTEE
FINAL !®�r "(o '/ G�,/,Ni.•6� Af�
LIDATION ARTHUR C. VEIJJ '
-SUPERVISING ELECTRICAL ENGINEER
' CK MO CASH - '
v
WORKERS'COMPENSATION DECLARATION CE-663 10/81 APPLICATION' FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self insure, CE-Bose
or a certificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof Sec 3800,La .C.) '
Policy-No. e Company'- FOR APPLICANT TO FILL IN JOB
ADDRESS ,�C� '
r-1Certified copy is hereby furnished New Residential Bldgs & Pools EACH NO FEE
1 & 2-Family,Sq .Ft $ — $ LOCALITY
Certified copy is filed with the c my building inspection —
NEAREST
d a met � Multi-family Sq Ft. CROSS ST -
Residential Swimming Pools
Date Applicant r OWNER OR
/ r ••'�� •.� ti.'a, FIRM NAME
= •... U •4;•. 1, 1,1,
CERTIFICATE OF EXEMPTION FROM WORKERS' - ,� ,•�? �. a•,
Outlets Rec Light Sw MAIL
' COMPENSATION INSURANCE•• 't ADDRESS,
First 20
(This section need not be completed if the work involved by the i -CITY Tel No.
permit is for one hundred dollars($100)or less.)- Total No Additional
70
I certify that in the performance of the,work for which this permit PLAN CHECK
- PPLICANT- -
is issued, I shall not employ any person in any manner so as to
become subject to the-Workers'Compensation Laws Lighting Fixtures First 20 ADDRESS
. -2, Additional
Total No ' CITY.." Tel No
Date Applicant
NOTICE TO, APPLICANT ,If, after .making this Certificate, of Fixed Appliances Not Over'1 HP PERMIT r
cExerription,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 _ WH _
LICENSED CONTRACTORS DECLARATION Hood Fan _ Other_ - CITY Tel'No ///
�'
I hereby_affirm that,I am licensed under provisions of Chapter 9 Disp Room'Alr-Gond LICENSE OR Class
(commencing with Section 7000) of Division 3 of the Business and REG NUMBER
Professions Code,and my license is in full force and effectDISTRICT NO PROCESSED Y `-
Power Apparatus& Large Appliances
��
Size 8 Type HP,KW,KVA,or KVAR L•(/ 0
License Numb Lic.Class U
Up to 1 Inc] FINAL
Over 1 to 10 Incl DATE �• ��V
Contractor Date,— VAL -TION '
❑ Over 10 to 50 Incl.
FIN&V
I am exempt under Sec Over 50 to 100'Inc.' B 292 5 5,A W
B,BPC for this reason Over 100 IL
#
• c Services,Swbd.,MCC& Paneltioards 0000)02 - Z.
Date. 0- 200 Amp Under 600 V o l 9.50
Signature 201 -- 1000 Amp Under 600 V
El
Over 1000 Amp. or Over 600 V - 0,0 o ,9,5
Exemption for Reg Maint Elect
r SINGLE FAMILY `. Temp-Power Pole-&_Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit - 3'2 8"$8'
I hereby affirm that I am exempt from the Contractor's License Law Additional Sign Branch Circuits
for the following.reason(Section 7031.5, Business and Professions
Code)
❑ I,as owner of the property,will do the work and the structure Misc Conduits-&Conductors
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule)
and Professions Code). , r
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(Sec 3097, PERMIT FEE (Sub-Total)
M1..
• 'Civ.C.)
PLAN CHECKING-FEE
Lender's Name
PERMIT ISSUING FEE
Lender's Address
I certify that 1 have read this application and state that the above TOTAL FEE "
information is correct I agree to comply with all County ordinances
and State-T21ws regul4ting Electricalwiring, and hereby authorize 1
repres tat ivIs of this County to enter upon the above-mentioned
proper fo•inspection purpos
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of'Permittee bate