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76A663-CES06 B-62 APPLICATION FOR ELECTRICAL PERMIT
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER BUILDING �iQUF n�♦� 1
BUILDING AND SAFETY DIVISION ADDRESS 1 N
JOHN A. E, COUNTY ENGINEER
A.JEN
WILLIAM A.JENSEN, SUPT OF BUILDING LOCALITY /-
NEAREST J -
FOR APPLICANT TO FILL IN cRoss ST.
RECEPT. TOTAL NO. EACH FEE
OUTLETS FIRST 20 $ 20 $ 00— MAIL
OWNER
LIGHT ADD'L .10 ADDRESS
SWITCH. OVER 20
LIGHTING TOTAL FIRST-20 .20 ,1 CITY /� ell' TEL. NO. /
FIXTURES ADD'L 10 v ELECTRICIAN
OVVR 20 vv
RANGES CLO.DRYERS WTR.HTRS., 1.001 1 1 ADDRESS '
GARB.DISP. STA.COOK
CITY TEL.
DISHWASH. AUTO.-WASH. STATE
SPACE HTRS. STA.APP.(yy H.P.MAX.) .50 LICENSE NO.
MOTORS: OVER NOT OVER H.P. DIST CT NY GROUP I ZglgF, PR C BY
0 1- 1.00 Q
1 ' 3 I.so INSPECTION RECORD
' 3 S 2.00
S 1 s 2.50 '
15 50 3.00
IL
50 100 5.00 0
SIGNS: NO.TRANS-
NO.LAMPS O
H(�
SERVICE 0.60OV-NOT OVER 200A 1.00 LL
a
SERVICE 0.60OV-OVER 200 A. 2:00 Lo
Z
SERVICE OVER 600V 5.00
M I SC.
i
PERMIT ISSUING FEE 2.00
SUPPLEMENTARY PERMIT ISSUING FEE 1.00
TOTAL FEE $
1HEREBY ACKNOWLEDGE THAT 1 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
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR �• ,y� G
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF FIXTURES nC
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE G 1
DESCRIBED RESIDENTIAL PROPERTY. POWER
SIGNATURE UTILITY CO.NOTIFIED
OF PERMITTEE
FINAL OPG
1DATION ARTHUR C. VETT
l/ C�K MO CASH SUPERVISING ELECTRICAL ENGINEER
176 .AW 2 2 .0 3.00
WORKERS'COMPENSATION DECLARATION<? ,:76A663 APPLICATION FOR ELECTRICAL- ,PERMIT
' CE-806G i2-80)
I hereby affirm that- I have-a certificate of consent to self COUNTY OF.LOS ANGELES1. BUILDING AND SAFETY
insure, or a certificate'of Workers'Compensation Insurance,or _ �,
a certified copy thereof(Sec. 3800,-Lab.C.)
f (�' /'�'f • 7 FOR APPLICANT TO EACH
IN JOB
y��,•f (�/'��f
Policy No!�Compan y (1(���•`!O�tT EACH NO. FEE ADDRES
t• y Neva Residential Bldgs.&Pools
O Certified copy is hereby furnished' 1 &2-Family,Sq. Ft. $ _ $ LOCALITY
Multifamily Sq. Vit. — NEAREST )+
Ceitified,copy is filed,with e county building inspection CROSS ST
de rt ent. Residential Swimming Pools OWNEROR Q
- FIRM NAME C� Ie✓
Date Applicant ! Outlets Re LI lit S,�7 i �� MAIL
First 20' .J ADDRESS
_ -CERTIFICATE OF•EXEMPTION FROM RKERS' Total No «�X�a Add`tional-" CITY'- Tel No. }
COMPENSATION INSURANCE,
"
l ' PLAN CHECK t1
sr APPLICANT 01'
(This section need not be completed, if the work involved Lighting Fixture First 20 �z1- V
by the permit is,for ,one hundred dollars ($100),or le'ss.) - ADDRESS -
/ ' Additional O
I Total NO. CITY j Tel No 4
I certify'that in the performance'of-the work for which this Fixed Appliances Not Over 1 HP' J 0
;permit is issued;I shall not employ any person.in'any manner PERMIT t + V
so'as to become subject to the Wo ers'.Compensation Laws. Range_ Heater�D.W. APPLICANT 1. 0 - 1� �'" d '
• - ,Co
Oven Dryer_W.M. ADDRESS, Z
Date Applicant Top _-FAU _W.H. — ^Y
U90Hood Fan _Other_, �. CITY Tel No �. (Jl
NOTICE TO APPLICANT:-If, after making this Certificate of Disp.-- Room Air Cond-_l., LICENSER v
Exemption,,;you' should--become,subject"to the Workers' REG. NOMBER� �� Class
'Compensation provisions of the Labor Code, you,must forth- - Power Apparatus& Large Appliances DISTRICT NO. P S BY
with comply with such provisions 'or this permit shall be
Size&Tj/e HP,KW, KVA,or KVAR
deemed revoked..
P 'Up to 1 Incl (/
FINA
Over 1 to 10 Incl.. DATE
LICENSED CONTRACTORS-DECLARATION 8 ( ' VALIDATI
- ,-. - Over 10 to�50 Incl,
I hereby.'affirm that I am licensed!under provisions of Chapter' Over,50 to 100,Inc._ FINAL
9 (commencing with.Section 7000) of Division'3 of the Busi- Over 100 BY - ° �r
ness and Professions Code, and my,license is in full force and`, t
effect. j Services
License Nu er 31 G Lic.Class �' l 0-200 Amp; Under 600 V l,t '
201,-1000'Amp. Under 600 V �
Contractor Date Over-1000 Amp.or'Over 600 V,f
HOME OWNERVBUILDER DECLARATION Temp. Power Pole,&Appurtenances
I,hereby affirm that I am exempt from the-.Contractor's` Sign with One Branch Circuit I
. License Law for, the following reason- (Section Additional Sign Branch Circuits 7031.5, Busi-
ness and Professions'Code): {
J Misc.Conduits&'•Conductors �3 6 5�.4 A
Other (See+Ce
O I, as owner -of,the property, will do the work and the ompleiFee,Sche ,
dulel-1
structure is not intended or offered for sale (Section #.o;o l0 0 0,2
7044, Business and Professions'Code).
CONSTRUCTION LENDING AGENCY• f -2' '0,'o;4 1,5 0
I hereby affirm' that there-is a construction lending agency t
for the performance of the work for which this'*permit is ' 2
issued-(S"ec. 3097,'Civ.C.)- p PERMIT FEE (Sufi-Totall. °I'O.°:4 1.Jr 1. 0,.6
Lender's;Name
t PLAN CHECKING FEE (One=Fourth Permit Fee) y . 1( 0 It 017 8 1
Lender's Address PERMIT ISSUING FEE,
I certify' that P have read this application and state,that the TOTAL FEE f ( ;
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 -
the a e-mentioned property for inspection purposes. -
n J, SEE REVERSE FOR•EXPLANATORY LANGUAGE t, r
th
'Signature of Per
ttee Date ;