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76A663-CE806 3-64
APPLICATION FOR ELECTRIC L PERMIT II'LJIII
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER BUILDING
BUILDING AND SAFETY DIVISION ADDRESS
�t;-JOHN A. LAMBIE. COUNTY ENGINEER
WILLIAM A. JENSEN, SUPT OF BUILDING LOCALIT
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
RECEPT. TOTAL NO. EACH FEE / `
OUTLETggg FIRST 2O 01.20 !S OWNER AMC / 0-5.5 o
LIOHT 17MAIL /.�,- 1• '
y / ADD'L 1O ADDRESS G'
SWITCH. -r OVER 20 7�_ ry
TOTAL CITY �" �� Cl// EL. NO 16 /,
LIGHTING L Flasr 20 � .20 �
FIXTURES ADD'L 10 ELECTRICIAN
0V9R 20
RANGES CLO.DRYERS WTR.HTRB. 1.00 ADDRESS
GARB.DISP. STA.COOK
CITY TEL. NO.
DIBHWABH. AUTO.-WASH. STATE
SPACE HTRB. BTA.APP.(yy H.P.MAX.) .SO
LICENSE NO.
MOTORS, OVER NOT OVER H.P. DIST ICT N G P ZONE P O E D
0 1 1.00 d
1 3 1.50 INSPECTION RECORD }
CL
3 a 2.Oo O
v
6 15 2.50
is 50 3.00
V
SO 100 5.00 Lu
D_
v7
SIGNSt NO.TRANS. Z
NO.LAMPS
SERVICE 0.600V.Nor OVER 200A 1.00
SERVICE 0.600V-OVER 200 A. 2:00
SERVICE OVER 600V 5.00
MISC.
PERMIT ISSUING FEE 2.00 oo
SUPPLEMENTARY PERMIT ISSUING FEE 1.00
TOTAL FEE
1 HEREBY ACKNOWLEDGE THAT 1 HAVE EAD THIS APPLICATION APPROVALS DATE INSPECTOR'S SIGNATURE
AND STATE THAT THE ABOVE 18 CORRECT AND AGREE TO COMPLY CONDUIT a
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
ELECTRICAL WIRING. / WIRING L .� i'/ �� �..a''�,';.✓7•�br;t
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR
LICENSED A8 RED BY L08 ANGELES COUNTY AND STATE OF
REQUIFIXTURES ^^�
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVEe t -
DESCRIBED RESIDENTIAL-PROPERTY. POWER
SIGNATUREV. UTILITY CO.NOTIFIED
' r !-r
OF PERMITTE
FINAL ' /U
VALARTHUR C. VETT
MO
CK MO CASH SUPERVISING ELECTRICAL ENGINEER
��1 8 3 8 4� r 8 2 D 4.0 0�
WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12-91)
76A663 APPLICATION FOR ELECTRICAL PERMIT
I herby affirm that I have a certificate of consent to self insure,
or a certificate of Worker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV.
copy thereof.(Sec.3800 Lab. C.)
Policy No. Company FOR APPLICANT TO FILL IN JOB
❑ 1.
ADDRESS /V
NO. EACH FEE LOCALITY L� e
Certified copy is hereby furnished. New Residential Bldgs.&Pools —
1&2-Family,Sq.Ft. — $ $ A
Certified copy is filed with the county b ildin1 T
9 inspec' NEAREST 1..�
epart ant. / Multi-family Sq. Ft. CROSS ST. lJ
Date �� Applicant , ..,/ Residential Swimming Pools ASSESSOR
`�— MAP BOOK PAGE PARCEL
CERTIFICATE OF EXEMPTI FRO RKERS' Outlets:Rec._Light Sw. OWNER
NAME
COMPENSATIO INSURA E First 20
(This section need not be com feted if the work involved by the ADDRESS
permit is for one hundred dollars($100)or less.) Total No. Additional M
I certify that in the performance of the work for which this permit CITY Tel.NO. 9&-2 9
1
is issued, I shall not employ any person in any manner so as t0 PLAN CHECK
become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 APPLICANT i ly
C)
Total No. Additional ADDRESS
Date Applicant RESIDENTIAL APPLIANCES NOT OVER 3 HP. � )
NOTICE TO APPLICANT: If, after making this Certificate of CITY V TeI.No.
Exemption,you should become subject to the Workers'Compensation OTHER APPLIANCES NOT OVER 3 HP.
provisions of the Labor Code, you must forthwith comply with Such PERMIT
p y Power Apparatus&Large Appliances APPLICANT
provisions or this permit shall be deemed revoked.
LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS
I hereby affirm that I am licensed under provisions of Chapter 9 Over 3 to 10 Incl.
(commencing with Section 7000) of Division 3 of the Business and CITY Tel.No.
Professions Code,and my license is in full force and effect. Over 10 to 50 Incl. >_LICENSE ^ Cl
C �M Over 50 t0 100 Incl. REG.NUMBER ass ER � �
2 Over 100 DISTRICT NO. PROCESSED BY O
License Number 000 Lic.Class�7 X4,1.-/ V
Services, wb�C&Parygl,bgar�lsj
Amp.Und�erOO V FINAL
Contractor Date DATE F-
❑ m exempt u r Sec. 400-1000 Amp.Under 600 V `�4 W
Over 1000 Am or Over 600 V VALIDATION
P• FINAL / a
B.&P.C.for this reasonBY
BRANCH CIRCUIT FEES G�GvCt� Z
Date: 15A,or 20A,120V,Lighting or Recept. Z
1 To 10 Branch Circuits
Signature 11 To 40 Branch Circuits
El
41 Or More Branch Circuits ,f
Exemption for Reg.Maint.Elect. 15A,20A,208V To 277V Lighting Br.Circuits
SINGLE FAMILY
Temp.Power Pole&Appurtenances 'it't'•` °$
HOMEOWNER-BUILDER DECLARATION 37303 «.7°rij
1 hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits i T
Code): 1 HEMS-*
EfI_
ElI, as owner of the property,will do the work and the structure Misc.Conduits&Conductors =t' 2
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) I I-r'f,V
and Professions Code). t"�L "r' �4
CONSTRUCTION LENDING AGENCY C111iANG-E
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)
Civ. C.) I!i_tij t-i €i)i _r `!
PLAN CHECKING FEE - ;
Lender's Name =s`� i ��s''i r
PERMIT ISSUING FEE f0
Lender's Address
I certify that 1 have read this application and under penalty of purjury state TOTAL FEE
that the above information is correct. I agree to comply with all County
ordinances and Stat laws regulating Electrical wiring,and hereby authorize
represent e o his County to nter upon the above-mentioned property
for ins o rposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
S17RE OF PERMI DATE