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6A663-CE806 5-62 APPLICATION FOR ELECTRICAL PERMIT
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER BUILDING
BUILDING AND SAFETY DIVISION ADDRESS G�-
JOHN A. LAMBIE. COUNTY ENGINEER 1
WILLIAM A. JENSEN. SUPT OF BUILDING LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST. LjG �M /I N'
2 TOTAL
TNOACH FEERECEPT. FIRST 20 6OWNER
OUTL TS MAIL
LIGNTA 00'L A� ADDRESS
OER 20 //—
TOT L CITY TEL.LIGHTING 12
FIRST 20
FIXTURES ADD'L 10 ELECTRICIAN
OV R 2D
RANGES CLO.DRYERS WTR.HTRS, 1.00 ADDRESS
GARB.DISP. STA.CORK
CITY TEL.NO C
DISH WASH. AI O.-WASH. STAT ^ '�
SPACE HTRS. T/STA.APP.I%H.P.MAX. .50 LICENSE NO.
MOTORS: OVER NOT OVER H.P. DISTRICT NO. GROUP ZONE PROCESSED BY
((, o — 1 1.00 p S'o 1- —I G O L-O V IC Q'
1 3 1.50 INSPEECCTTIIONrRECORD /7
ear) X
6 15 2.50 ' / \ %� I 'f. 7.�✓ a
15 50 3.00 v - " O
50 100 5.00
O
1—
SIGNS; NO.TRANS. U
NO.LAMPS W
2
H
SERVICE 0.600V-NOT OVER 200A 1.00 Z
SERVICE 0-60OV-OVER 200 A. 2.00
SERVICE OVER 600V 5.00
MISC.
PERMIT ISSUING FEE 2.00
6UPPLEMENTABY PERMIT ISSUING FEE 1.00
TOTAL F 6
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI FIT 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 q
ELECTRICAL WIRING. WIRING J
I HEREBY CERTIFY THAT 1 AM PROPERLY REG15TEKED ANO/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF FIXTURES -` }�J1.
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL P PERTY. POWER f
SIGNATURE UTILITY CO.NOTIFIED
OF PERMITTE ,(
FINAL i^A'6LY, ,•e.-
VALIDATION ARTHUR C. VEIT
CK MO CASH SUPERVISING ELECTRICAL ENGINEER
2 1 7 6 18 2 D 1 4.60- fV
i�1X/7�/�Zlt�rr�
WORKERS'COMPENSATION DECLARATION 19-563 ,Dre, APPLICATIONFOR ELECTRICAL PERMIT
{J
I hereby affirm that Ihave --a certificate of consent'to self insure, CE-806G �J
or a certificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
cop�W�t1A.r-or P(Sec. 380 Lab, C.) / y / ' ///t f
Policy No /� Company AAy'U iry A l- FOR APPUCANT.TO FILL IN JOB
ADDRESS /�/� (Ji) /l.Vr/�
❑ Certified copy is hereby furnished. New Residential Bldgs. &.Pools rEACHNO. FEECertified copy is.filed with. the.county-building inspection 1 & 2-Family,Sq.Ft. — $ LOCALITY
-r department. Multi-family Sq.Ft.
NEAREST
q{ �• �no _ CROSS ST A//
Dat �,�/•� 7/" ie.14�lsylz "/ Residential Swimming Pools OWNER OR
Date ' Applicant
' FIRM NAME
,CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Ree—Light _ Sw. MAIL n
COMPENSATION INSURANCE t ADDRESS. Ql /[ 0
(This section need not be completed if the workinvolved by theFirst 20
permit is for one hundred dollars (5100)or,less.) Total No. Additional CITY ,e (V) Tel.No. IIy -dZf D
I certify that In the performance of the work.for which this permit _ PLAN CHECK
APPLICANT
is issued.] 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.
Date Applicant Fixed Appliances Not Over 1 HE NOTICE. TO APPLICANT: If, after making this Certificate of PERMIT /� n C
Exemption,you should become subject to the Workers Compensation Range_ Heater_ D.W. _ APPLICANT U/✓/v0/� A(2. C/NzC .�/✓
provisions of Via Labor Code, you must forthwith comply with such Oven _ Dryer T W.M. ADDRESS 31 ,r/v4N/
provisions or this permit shall be deemed revoked n Top — FAU Z W.H. _ ,3 So -
.` CITY. � �e 0" Tel.No G 1S
LICENSED CONTRACTORS DECLARATION Hood Fan Other_
I hereby affirm that 1 am licensed under provisions of Chapter 9 LICENSE OR 77 q
(commencing with Section,7000)of Division 3 of the Business and Disp. ROOM Air Cond. REG.NUMBER 0J J.J a e2d C
Professions Code,and my license is in full force and effect. DISTRICT NO. _ / P SED v
Power Apparatus& Large Appliances � fX(// d
r q/ Size& Type HP,KW,KVA,or KVAR /
License Number 79rJ1-1 _fc.CJassJr.1V 121.7 Up to 1 Incl FINAL V
/�� ��- O Over 1 to 10 Incl DATE
/AJ//Y/� 12!12 � 102 Date y 34- 7� VALIDATION O
Contractor Over 10 to 50 Incl.
❑ FINAL - U
lam exempt under Sea - Over 50'-
O to 100 Inc. By
W
B.&P.C.for this reason Over 100 d
Services,Swbd.;MCC &Panelboards - - - , - N
Date: 0 - 200 Amp.Under 600 V ea
Signature 201 -1000 Amp.Under 600 V
- Over 1000 Amp.or Over 600 V
Exemption for Reg.Maim.Elect.
SINGLE FAMILY Temp.Power Pole & Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit ACCTS
I hereby affirm that I am exempt from the Contractor's License Law 7 I[1
for the following reason(Section 7031.5, Business and Professions '3307 it .[
Code): Additional Sign Branch,Circuits 1 ITEMS
❑ I,as owner of the property,will do the work and the structure Misc.Conduits& Conductors
is not intended or offered for sale (Section 7044, Business Other (See Complete Fee Schedule) _ TOTAL g' m 00
and Professions.Code). -
CHECr, 17.00
CONSTRUCTION LENDING AGENCY - - L' „
I hereby affirm that there is a construction lending agency for.the - CHAN6E
performance of the work for which this permit is issued(Sec.3097, PERMIT FEE: (Sub-Total) 3 g
Civ.CT. '
PLAN CHECKING FEE, r 0000-0001 2/12/90
Lender's Name
PERMIT ISSUING FEE 0 8886 1 AM 10:33
Lender's Address
I certify that I have read this application and state that the above TOTAL FEE 7,
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 - - - -
proper y forinspection purp s.
- .dp SEE,REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date