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76Ae7D-Cee06 8.E9 APPLICATION FOR R ELECTRIC PERMIT - 1
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER1777
(�BUILDING AND SAFETY DIVISION Ti j.• (e'1O1JOHN A. LAMBIE. COUNTY ENGINEERCASSATT D. GRIFFIN,SUPT OF BUILDING
FOR APPLICANT TO FILL IN NEAREST
PERMT FEES CROSS ST.
OWNER
ITEM NUMBER I EACH FEE MAIL
OUTLET / � ADDRESS
LIGHTS RECEPT./ ' SW. .10 a
LIGHTING FIXTURES 10 CITYTRie
NOUARIL.
ELEC.RANGES CLO.DRYERS ELECTRICIA
WATER HEATERS .50 ADDRESS 9,oz w.,
'
OAD
ELEC.SPACE HTRS. DISHWASHERS CITY ARCADIA,
GARBAGE DISPOSERS AUTO.- STATE r, Y63 Hl, 6-8341
WASHERS STA.COOKING UNITS .25 LICENSE NO.
MOTORS: OVER INC. .. .2S �ry DISTRICTT,�V0... I GR UP I JE P CESSED BY
0— 1/2 � �1
1/2— 2 .SO INSPECTION RECORD
2— 5 1.00
5— 18 1.50-
15—
.50-15— SO 2.50
50—200 5.00
SIGNS: NO.TRANS.
NO.LAMPS
SERVICE 0-600V 1.00 Q�
SERVICE OVER 600V 5.00
MISC.
WIRING PERMIT 1.00 ]ABOVE-
QFIXTURE PERMIT 1.00SUPPLEMENTARY PERMIT .50
TOTAL FEE1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THISN [FINAL.
PROVALS DATE INSPECTOR'S SIGNATURE
AND STATE THAT THE ABOVE IS CORRECT AND AGRELYWITH ALL COUNTY ORDINANCES AND STATE LAWSG T ELECTRICAL WIRING.
IHEREBY CERTIFY THAT 1 AM 'PROPERLY REGISTOR LICENSED A8REQUIRED BY LOS ANGELES COUNTY AOF SCALIFORNIA OR THAT 1 AM THE LEGAL OW ER OVEDESCRIBED RESIDENTIAL PROPERTY.SIGNATURE { CO.NOTIFIED
'
OF PERMITTE �.�e
�' ,ip/�,
®p, CASH ARTHUR C.VETT,
- CK o CASH SUPERVISING ELECTRICAL ENGINEER
g7 6 7 7 8 - OCT 3 0 2 'A 7.2 5
WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12-91)
76A663 APPLICATION FOR ELECTRICAL PERMIT
I hereby 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
Policy No. Company FOR APPLICANT TO•FILL IN's JOB '��� n' '
❑CYC.y. u - - - EACH'
- ADDRESS yt'C_/ ,
Certified copy is hereby furnished:' New Residential Bldgs &Pools y NO EACH` FEE _(
�. —, , - ,
._ _ $ $ LOCALITY
Certified co is filed with the count building inspection 1 &2-Family,Sq. Ft.
v PY Y 9 P NEAREST
department Multi-family Sq Ft. CROSS ST f LJ C
Date Applicant Residential Swimming Pools ASSESSOR
SS SSOR
c MAP PAGE PARCEL
y, e CERTIFICATE OF EXEMPTION FROM WORKERS' \ Outlets.Rec._Light Sw FIPM NAME
COMPENSATION,INSURANCE First 20
MAIL
( P,
This.section need not be,com leted if the work Involved by the
Total No Additional y\.x ADDRESS
•• -
pe?mlt is foi one hundred dollars($1o0)or less.) /
"-" CITY
/► f•C� '"Tel No
I certify that+in'tha performance of the work for which this permit C"•i� C
is issued, I shall not employ any person In'any-manrier so as to PLAN CHECK
become subject to,th_e Workers'Compensation Laws, Lighting Fixtures First 20 —APPLICANT t
Total No Additional
ADDRESS
Date' +~�O'r phcant� + • '- '� •� • `
RESIDENTIAL APPLIANCES NOT OVER 3 HP
NOTICE TO APPLICANT: If, after making this'Certificate of CITY Tel No
Exemption, you,'should become subject to the Workers' Compensation OTHER APPLIANCES NOT OVER 3 HP
revisions of the Labor Code, you must forthwith comply with such PERMIT /
P Y P Y •APPLICANT` -
provisions or this,perrriit'shall be deemed revoked '•. � - Power Apparatus'&Large Appliances
LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS
I hereby affirm'that I am Ilcensed'und'er provisions'of-Chapter 9
(commencing with Section 7000) of Division 3 o0the Business and Over 3 to 10 Incl. CITY Tel No
Professions Code, and my license is in full force and effect. Over 10 to 50 Incl.
LICENSE OR
Over 50 to 100 Ind REG NUMBER Class a
Over 100 DISTRICT NO P O SED BY O
License Number Lia Class '
Services,Swbd.,MCC& anelbo rds: . 49 V
FINAL
Contractor Date 093 Amp. n eU d r 600 V DATE 0
❑ 400-1000 Amp Under 600 V O� VALIDATION V
I am exempt under Sec
Over 1000"Amp.or Over 600 V FINAL a
B.&P C for this-reason BRANCH CIRCUIT FEES BY
Date: 15A,or 20A, 120V,Lighting or Recept. Z
•- 1 To 10 Branch Circuits '
Signature 11 To 40 Branch Circuits
41 Or More Branch Circuits
❑ Exemption for Reg Maini Elect 15A,20A,208V To 277V Lighting Br Circuits
SINGLE FAMILY Temp Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION
Sign with One Branch'Circuit
I hereby affirm that I amlexempt from the Contractor's License Law g
for the following reason (Section 7031 5, Business and Professions Additional Sign Branch Circuits' _ —
Code
Misc.Conduits&Conductors r .'V
- I, as owner of the property,will do the work and the structure - '- - �• �t=f`•'-'
is not intended or offered for sale (Section 7044, Business -Other(See Complete Fee Schedule) t IiT{,yL �a s
and Professions Code)
• CONSTRUCTION LENDING AGENCY _ 59,�r"t
I hereby affirm that there is a construction lending agency for the ;HNK="
performance of the work for which this permit is issued (Sec 3097, PERMIT FEE, (Sub-Total) f -
Civ. C) j f.
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE c f'
Lender's Address - rc�r-:+
•�. H �.l=D'i
I certify that I have read this application and under penalty of purjury state TOTAL FEE �5
that the 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 above-mentioned property '
for inspection purpose SEE REVERSE FOR EXPLANATORY LANGUAGE
IG URE PERMITTEE 0 DATE '