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76A663-CE806 9-69 APPLICATION FOR ELECTRICAL P.PRMIT
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER BUILDING cp I
BUILDING AND SAFETY DIVISION ADDRESS (J /®,S O dA/C4JOHN A. LAMBIE, COUNTY ENGINEER
COLEMAN W. JENMINS. SUP'T. OF BUILDING LOCALITYMM NEAREST
FOR APPLICANT TO FILL IN CROSS ST.TOTAL , _NO. EACH //��){ OUTLETS FIRST 20 520 $ OWNER �i Abnc4 e(LIGKi �� T MAIL
SWITCH./ �1� ADD'L f0 ADDRESS
OVER 2O L�,LIGHTING TOTAL ; FIRST 201 ,20 'L'L/ CITY TEL. NO.FIXTURES } l0 — AOD'L 10 ELECTRICIANov R 20 RANGES CLO.DRYERS WTR.HTRS. 1.00 ADDRESSGARB.DISE. STA.COON CITVTEL.NO. �DISHWASH. AUTO.-WASH. $TATE SPACE HYRS. STA,APP.(/H.P.MAX.) .50 LICENSE NO.MOTORS: OVER NOT OVER H.P. DIST�CT O. UP P
O 1 1.00 _ 'Jr /
1 a 1.so INSPECTION RECORD
s B 2.00 t_ ,+s/l o_{.. 1f «' 0
/
8 15 _2.50 /J ee, /(A'�iL\
15 50 3.00 �. w. /11[��C.ei 3' A
eea
50 100 5.00
SIGNS:
NO.TRANS- �II w / /}{/JI'VE- /,}O IY
NO. LAMP9 YT ,.lA,w i9�� AM1Y�r�1%' 13� /ar�wY" • h
SERVICE 0.6001 OVER 200A 1.00
SERVICE 0-600V.OVER 200 A. 2,00 s ai ,
SERVICE OVER 600V 5.00
MISC. /.'T�7'ff n7"'
t
PERMIT ISSUING FEE 2.00
SUPPLEMENTARY PERMIT ISSUING FEE 1.00
TOTAL FEE $
I HEREBY ACKNOWLEDGE THAT 1 NAVE READ THIS APPLI ATION 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
HEREBY CERTIFY THAT I AM PROPERLY REGISTERED ANO/OR I
LENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF FIXTURES
CALIFORNIA OR THAT I AM THE LEGAL D DF. AND INTEND TO
RESIDE IN, THE ABOVE D P
RESID L ROP RTY, POWER
SIGNATURE UTILITY CO.NOTIFIED
OF PERMITTEE_
FINAL 7
VALID AT JOSEPH C. ROOHAN
CK MO CASH SUPERVISING ELECTRICAL ENGINEER
3112 Ju?128 2 D 9.80-
Q
i /
76A6,6
—WORKERS't I have
a cerN DECLARATIONconsent
CE-803 10i91 APPLICATION FOR ELECTRICAL PERMIT
,'I hereby-affirm that I have o certificate of consent to self CE-806G
insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified copy thereof (Sec. 3800, Lab. C.)
Policy No. Company FOR APPLICANT TO FILL IN ADDRESS pa5 /�Mosfl
-IpQI Certified copy is hereby furnished. New Residential Bldgs. 8 Pools EACH NO. FEE L
❑ Certified copy is filed with the county building i c- 1 & 2-Family, Sq. Ft. $ — $ LOCALITY A/4. G/ L.A1 TleN�
yp � 0 I — NEAREST 0
jion)d ep rtment. /l Multi-family Sq. FLS=4 CROSS ST. V
Date VO ✓L/ Residential Swimming Pools
OWNER OR
3 C-
CERTI KATE OF EXEMPTION FROM WORKERS' - - EFIIRRM NAME
Outlets: Rec_Light_Sw.
COMPENSATION INSURANCE First 20 ADDRESS p I •/
(This section need not be completed if the work involved by Total No. Additional CITY 5�. f,I
the permit is for one hundred dollars ($100)or less.) 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.
Dote Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, after making this Certificate of (jig L- ri.
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._ ADDRESSI y i3• L�W% ✓
with comply with such provisions or this permit shall be Top _ FAU —W.H. — a ^O (�
deemed revoked. CITY t Tal. No. ! o
LICENSED CONTRACTORS DECLARATION Hood _ Fan _ Other_
ICENSE OR
Disp. — Room Air Cond. 7 Class.
I hereby affirm that I am licensed under provisions of Chapter 9 REG. NUMBER �"7 �� � —to }
(commencing with Section 7000) of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO. r, PROCE E Y �-
and Professions Code,and my license is in full force and effect. 5.O O
C p Size 8 Type HP, KW, KVA, or KVAR
License Number ic. Class FINAL
,,II Q Up r 1 Incl. / �j
Contractor `I Date 7 O Over 1 to 10 Ind. DATE _ G �Z{ VA ATION U
❑ Over 10 to 50 Incl. FINAL- CJ W
1 am exempt under Sec. Over 50 to 100 Inc. BY �
B.&P.C. for this reason Over 100 Z
Services, Swbd., MCC& Ponelboords 3 81,6 A —
Dote: 0 - 200 Amp. Under 600 V ► is o s e e
Signature 201 - 1000 Amp. Under 600 V 2
❑ Exemption for Reg. Mainz. Elect. Over 1000 Amp. or Over 600 V .) a 1 1 6 9 4
SINGLE FAMILY Temp. Power Pole& Appurtenances ° ^ 1 1 6 9 4 v
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit Q 1. 1 4 -86
I hereby affirm that I am exempt from the Contractor's License Additional Sign ranchBronc .Circuit
is
Law for the following reason (Section 7031.5, Business and
Professions Code):
❑ I, as owner of the property, will do the work and the Misc. Conduits 8 Conductors
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ Poo7044, 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 d
Lender's Address
I certify that I have read this application and state that the TOTAL FEE 6
,11
above 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
propppppp
the above-mentioned rrr��yyyy for ' sped io purposes.
' �� SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee If pot