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76A663-CE606-7-56 APPLICATION F®R ELECTRIC PERMIT
1
BUILDING AND SAFETY DIVISION
Department of County Engineer BUILDING
County of Los Angeles ADDRESS 66
JOHN A. LAMBIE, COUNTY ENGINEER /
CASSATT D. GRIFFIN, SUP'T OF BUILDING LOCALITY v
r
FOR APPLICANT TO FILL IN NEARESTCROSS ST.
PERNUT FEES
NUM ER OWNER /
ILf LIGHT OUTLETS MAIL
ADDRESS
RECEPTACLES ,
WALL SWITCHES FEE CITY TEL NO.
TOTAL OUTLETS @ 5¢ $ ELECTRICIAN c
ELEC RANGES 25 ADDRESS
ELEC HEATERS 25 �� CITY TEL. NO.
KW EA STATE-77
LICENSE NO
FIXTURES 5
MOTORS , DISTRICT NO. AZONE READY FOR INSPECTION
NUMBER HORSEPOWER FEE JGROIJP �
NEW MVD HP OVER INC EACH
11 8:LESS $ 25 - INSPECTION RECORD
Yz, 2 50
2 5 1 00
5 15 1.50
15 50 2 50
50 200 5 00
MISC
NO SIGNS NO TRANS
NO SIGNS NO LAMPS
FOR EACH PERMIT -
WIRING PERMIT $100
FIXTURE PERMIT $1.00 /
SUPPLEMENTARY .50 APPROVALS
- TOTAL FEE $ DATE INSP -CTOR;S SIGNATURE
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CONDUIT
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY ..^
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING WIRING _2 /•]
ELECTRICAL WIRING FIXTURES ,-/
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR 6e4�L
LICENSED AS REQUIRED BY LOS ANGELES 001DNTY AND STATE OF POWER
CALIFORNIA OR THAT M THE LEGA O NER 01 T E ABOVE
DESCRIBED RESID�x L R E TY. , UTILITY CO.NOTIFIED
SIGNATURE i
OF PERMITTEE FINAL `7
JOHN A. LAMBIE. ARTHUR C. VEIT.
COUNTY ENGINEER c Mo 'OLIDATION SUPERVISING ELECTRICAL ENGINEER
LG 6 2-5 C- f�JAR 21 2 6.15 to
WORKERS'COMPENSATION DECLARATION ,o/B, APPLICATION FOR ELECTRICAL PERMIT '
I_her�)y,�gffirm-that I have a certificate of consent CE-806 to self CE-806G
unsure, or a certificate of Workers'•Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a'certified copy thereof (Sec 3800, Lab C ) ;
J Policy No Company FOR APPLICANT TO FILL IN JOB
ADDRESS (p� �-+�� vv
Certified copy is hereby furnished New Residential Bldgs & Pools EACH NO FEE
❑ Certified copy is filed with the county building mspec 1 &2-Family, Sq Ft $ — $ LOCALITY �I�C C1
NEAREST
l cJf department pp ��y Residential
wi Ft CROSS ST (f
Residential Swimming Pools _ OWNER OR
Date - A Ilton
� i,',.� FIRM NAME
CERTIFICATE OF EXEMPTION FROM,WORKERS' �- Sw E MAIL
Outlets Rec Light
COMPENSATION INSURANCE ' I ADDRESS
(This section need not be completed if the work involved by First 20
the permit Is for one hundred dollars ($100)or less.) Total No Additional CITY *'t�� � Tel No'Z�� b0 3
PLAN CHECK
I certify that in the performance of the work for which this APPLICANT
permit 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
Total No Additional
CITY Tel No
Date Applicant Fixed Appliances Not Over I HP PERMIT
NOTICE TO APPLICANT If, after making this Certificate of APPLICANT
Exemption, you should become subject to the Workers' Range_ Heater_D W
Compensation.provisions�of the Labor Code, you must forth- Oven _ Dryer W M ADDRESS CA
/v
with comply with, such provisions or this'permit shall be 'Top FAU —W H
deemed revoked CITY Tel No 60
LICENSED CONTRACTORS DECLARATION Hood _ Fan _ Other_ t
Disp Room Air Cond LICENSE OR ` Class
I hereby affirm that I am licensed under provisions of Chapter 9 REG NUMBER 3
(commencing with Section 7000) of Division 3 of the Business DISTRICT NO PROCESS Y
and Professions Code,and my license is in full force and effect Power Apparatus& Large Appliances 0CL
-(�
Size & Type HP, KW, KVA, or KVAR a 0
License Number Lic Class Up to 1 Incl FINAL L.7
' Over 1-to 10 Incl DATE VALIDATION "0
Contractor Date Over 10 to 50 Incl
UJI
IL
F-1FIN
I am exempt_underOver 50 to-100 Inc
,Sec BY
B&P C for this reason Over 100
_ x,21 Q 4 A $A
' Date Services, Swbd , MCC & Panelboards -
0 -200 Amp Under 600 V ► # o 0 0 0 0 2
Signature 201 '1000 Amp' Under 600 V "
❑ t,
Exemption for Reg Maint Elect Over 1000 Amp or.Over 600 V •( -,Q 4 350
SINGLE FAMILY Temp Power Pole &Appurtenances
HOME OWNER-BUILDER DECLARATION 0 -'- 43505
Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License s
Law for the following reasonAdditional Sign Branch'Grcuits
(Section 7031 5, Business and 04_23 8 5
Professions Code)
❑ j, as owner of the property, will do the work and the Mi sc Conduits& Conductors
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ ►
7044, Business and Professions Code)
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 PERMIT FEE - (Sub-Total)
(Sec 3097, 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 TOTAL FEE 132-01
above information is correct I agree to comply with all County
ordinances and State jaws regulating Electrical wiring, and )
hereby authorize representatives of this County to enter upon
f-tke above- ntioned property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE _
Signature o ermrtm Date