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��CAL MEMUISA663-CE808 5 = PPUC = OM FOP,
LOUNTY
OF LOS ANGELES
,DEPARTMENT OF COUNTY ENGINEER BUILDING
BUILDING AND SAFETY DIVISION ADDRESS
JOHN A. LAMBIE, COUNTY ENGINEER Tv .
WILLIAM A. JENSEN, SUPT OF BUILDING LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
RECEPT.le TOTAL NO. EACH FEE
OUTLETS FIRST 20 $20 $ OWNER
LIGHT j• MAIL
A DD'L f0 ADDRESS
SWITCH. OVER 20
TOTAL Z� CITY 1 TEL. NO.
LIGHTING FIRST 20 .20 _
FIXTURES I OV R'L 10 ELECTRICIAN
RANGES CLO.DRYERS WTR..HTRS. 1.00 ADQRESA
GARB.DISP. STA.COOK
CIT � � TEL.NO.L& -L1
DISHWASH. AUTO.-WASH. STATE
SPACE HTRS. STA.APP.(%H.P.MAX.) .50 LICENSE NO.
MOTORS: OVER NOT OVER H.P. DIStTRIC'T NO a Gr OU,. Z 'N P SED ELY
O 1 1.00 �/ ( i_ 3
1 • 3 1.50 INSPECTION RECORD
3 B 2.00
8 15 2.50 a
O
15 50 3.00 - V
50 100 5.00
O
NO.TRANS ~
SIGNS' NO.LAMPS IVLI
to
- SERVICE 0.600V-Nor OVER 200A 1.00 Z
SERVICE 0-60OV-OVER 200 A. 2:00
SERVICE OVER 600V 5.00
MISC.
PERMIT ISSUING FEE 2.00 Z
SUPPLEMENTARY PERMIT ISSUING FEE 1.00
TOTAL FEE
1 HEREBY ACKNOWL E THAT 1 AVE READ IS APPLICATION APPROVALS DATE INSPECTOR'S SIGNATURE
AND STATE THAT TH AB VE IS C REG AN REE O COMPLY �✓iA /',J
WITH ALL COUNTY ORDI ANCES ND AT AWS GUL ING CONDUIT �•,eR.�l '"'},' r f",l'11::.°Sr`•�'�'. '-'�
ELECTRICAL W.R. WIRING
1HEREBY CERT Y TH T I AM PRO RL REGI TE D N /OR
LICENSED AS RE RED LOS NGE ES OUNT A S AT OF FIXTURES
CALIFORNIA OR AT 1 LE AL WNER O TH OVE /
DESCRIBED RESID TIA PROPE P' POWER
SIGNATURE UTILITY CO.NOTIFIED
OF PERMITTEE 6)+ ?
FINAL
VALIDATION ARTHUR C. VEIT U ✓
QMO CASH SUPERVISING ELECTRICAL ENGINEER
UtALo:7 6 0 9 1 NOV 2 9 2 D
4.20-
' 'JwRKEth COMPENSATION DECLARATION. CE-806 10/81 t n nnp N Foo ftp (iacTmC n L f�,12(7 rT
„ I'here'b>,.affirm that I have a certificate of consent to self CE-8066 h11Tlf-L� 1r�111 IlV l!- ll�l LSL�LS Il ll� L�1 lTlSh�lllJ❑
;dinsure,Jr a certificate of Worker's' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING ARID SAFETY
or a certified copy thereof (Sec. 3800, Lab. C. _
Policy No. Company FOR APPLICANT TO FILL IN., JOB
Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADDRESS a/
Certified copy is filed with the county building inspec- 1 8& 2-Family, Sq. Ft. $ — $ 'LOCALITY
-<,Z241 1-lZirl
tion department. Multi-family Sq. Ft.' — NEAREST
CROSS ST.
Date Applicant Residential Swimming Pools OWNER OR P
FIRM NAME.
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw.I ' � MAIL
mr
COMPENSATION INSURANCE ADDRESS
This completed if the-work involved b First 20
( section need not beom p 1/ Total No. CITY Tel. No. s (�
.� y
the permit is for one hundred dollars ($100)or less:) Additional
I certify that in The performance of,the work for which this PLAN
PNC CHECK
E K
permit is issued,'I shall not employ ' person in any manner
so as to become subject to the Wor er '.0 ensat.ion.,aws. Lighting Fixtures First 20 ADDRESS
Total No. \ 'f Additional
Date Applicant CITY Tel. No.
NOTICE O A PLICANT: ,If, after making th' Certificate of Fixed Applionces:Not Over 1 HIP PERMIT
Exemption, you should beco e subject to the Workers' Range_ Heater_D.W. APPLICANT
Compensation provisions of the Labor,Code, you must forth- Oven _ Dryer — W.M._ ADDRESS
with comply with 'such provisions or this permit shall be Top FAU —W.H.
deemed revoked. CITY Tel. No.
LICENSED CONTRACTORS DECLARATION' Hood _ Fan _ Other=
Disp' Room Air Cond. LICENSE OR Class.
I hereby affirm-that I am licensed under provisions of Chapter 9 REG. NUMBER
(commencing with Section 7000) of'Division 3 of the Business s lian
e A
Apparatus& Large Appliances DISTRICT NO. P CESS D BY
' y.
and Professions Code;and my license is in full force and effect.. � PowerApp ���
Size &Type HP, KW, KVA, or KVAR'. ®•
License Number Lic. Class fT'Up to 1 I-ncl. FINAL V
Over 1-to 10-Incl, U•D DATE VALIDATION
Contractor Date Over 10 to 50 Incl.
QFINAL I am exempt under Sec. Over 50 to 100 Inc. BY / _ W
Over 100
B.BP.C. for This reason Q)�
Services, Swbd., MCC & Panelboards
Date: 0 -200 Amp. Under 600 V D _
Signature 201 1000 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
I hereby affirm that I am exempt from the Contractor's License Additional Sign Branch Circuits J
Low for the following reason (Section 7031:5, Business and
Professions Code):
1, as owner of the property, will'do the work and the Misc. Conduits&.Conductors
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ z 6 Q 1.7 A
7044, Business and Professions Code). D
CONSTRUCTION LENDING AGENCY # o 0 0 0 0 2
l hereby affirm that there is a construction lending agency for 1 ®,0 3 1.7 5
the performance of the work for which this permit is issued PERMIT FEE (Sub-Total).;
(Sec. 3097, Civ. C.). 0 0 0 3 1,7 54F
PLAN-CHECKING FEE
Lender's.Name '
11,25=-86
PERMIT ISSUING FEE
Lender's Address
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 thorize representatives of this County to enter upon
the a ov -menti ned property for inspection purpos S.
SEE REVERSE FOR EXPLANATORY LANGUAGE
1
,Signal e'of Permitt a Date