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7SA663-CER06 5.62 APPLICATION FOR ELECTRICAL PERMIT r
COUNTY OF LOS ANGELES .:
DEPARTMENT OF COUNTY ENGINEER. BUILDING
BUILDING AND SAFETY DIVISION ADDRESS' O La Rosa
JOHN A. LAMBIE, COUNTY ENGINEER
WILLIAM A. JENSEN, SUPT OF BUILDING LOCALITY M.,l IS f%4
PPLICANT TO FILL IN CROSS ST. G11
F17
AL NO. EACH FEE '-,ETS FIRST 20 '20S.zO S f,� 00 MA NER
f rTp n OVER202� .10 2 9 ADDRESS 1�liF Le $088.AL L CITY Tem le Cit TEL.'NO.'
FYRST2012 .20 ' 2 1}Q12 AOD'L .10 ELECTRICIAN.
Dv R 20
.RANGES CLO.DRYERS WTR.HTRS. 1.00 - ADDRESS
GARB,DISP. STA..COOK
CITY Q$ TEL. NO.
DISHWASH. AUTO.-WASX. '1 ' STATE q p
SPACE XTRS. STA.APP.(1/2 H.P.MIX. ) 2 .50 1 00 LICENSE NO. 170188
'MOTORS: OVER NOT OVER H.P. DISTRIC,�NO. GROUP ON PJED
o — 1 1.00 _ p
1 a 1,501I INSPECTION RECORD
8 15 2.50 Via. - d
15 50 3.00 - T OV
50 100 15.00
O
NO.TRANS. ~
SIGNS:' NO.LAMPS V
I
N
SERVICE Ow600V+NOT OVER 200A 1.00 110 ?
SERVICE 0-60OV-OVER 200 A. 2:00
SERVICE OVER 600V 5.00
MISChiISSUING 2.00 '2100
ARY PERMIT ISSUING FEE 1.0.0
TOTAL FEE S 13
ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION -APPROVALS DATE INSPECTOR'S SIGNATURE
HAT THE ABOVE 19 CORRECT AND AGREE TO COMPLY CONDUIT / d
COUNTY'ORD I NANCES AND STATE LAWS REGULATING -w
WIRING. WIRING ' �
THEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR ,A "OA-
CALIFORNIA
-
'LICENSED AS REQUIRED BY LOS ANGELES�COUNTY AND STATE OF FIXTURES 1/� O L
CALIFORNIA OR THAT AM THE LEGAL OWNER THE ABOVE
DESCRIBED RESIDENTI PROPERTY. POWER
SIGNATURE
OF PERMITT UTILITY CO.NOTIFIED �� f ✓
FINAL /7 ,I
OCK .
I OCAS 'ARTHUR C. ELEMO CASH SUPERVISING ELECTRICAL ENGINEER
Lzio8 21 1f7 JUL —, 1 2 7 _1. 33
0wV.
Wm ihatd have a certificate
DECLARATION '!8.663 10,61 APPLICATION FOR-ELECTRICAL PERMIT. �{�
OE-a63 LJ
Thereby affirm'that.) have a certificate of.consent to self insure, � �
or a certificate of Workers' Compensation Insurance, ora certified . COUNTY OF LOS ANGELESBUILDING AND'SAFETY
copy thereof(Sec.3800,Lab. C.)
Policy No: Company i FOR APPLICANTITO FILL'IN - JOB - "I I�ty LA ROS/F. �R
. . .- -•
ElCerbtled'-copy Is hereby furnished New Residential Bldgs.&^Pools EACH.: NO. FEEADDRESS O LOCALITY "
❑ Certified copy is filed with.the county'building•inspection 1 8 2-Family,Sq.Ft. $ _ $
department - Multi-famil Ft f CROS SS , p
y NEARS SL
Date `- - Applicant Residential Swimming Pools� ,* NAME,
FIRM /vt_
I ME
CERTIFICATE OF EXEMPTION FROM WORKERS .. Outlets:Red Light Sw._f)' t �1 MNL r�
'COMPENSATION INSURANCE . - - ADDRESS O I-1 S •D ,
First 20
;(This section need not belcompleted if the work invol3etl by Me - �/ CITY, Tel No. qqq
permit Js for one hundred dollars ($100)or less.) Total No.—L{-- Additional - � Q�
I certify that,in the pedormance.of the work,for which.this permit APPLICANT K, �• A-&ot/
is issued. ].shall rot employ-any person in'any'manner so as to _
'become subject to the Workers Compensation.Laws LightingFixtures First 20^ Q,zi ADDRESS
Additional
4'114 f 8 Applicant r Total No. CITY ' Tel No.
Date Fixed Appliances Not Over 1 HP PERMIT f7 '
NOTICE TO APPLICANT: If, after makf6g,;this Certificate of APPLICANT ,J /}M� • CC
i
Exemption,you should-become subject to the Workers Compensation Range— Heater_ D.W.
'provisions of the Labor Code, you must forthwith comply.with such Oven _ Dryer W.M:— •ADDRESS _
provisions oe,this permit shall be deemed-revoked. Topa _.FAU W.H. CITY - Tel.No.`
1 LICENSED CONTRACTORS DECLARATION. Hood — Fan Other l
b hereby,affirm,that.I am license- under provisions of,Chapter 9 Disp. Roo Air Coed] Z LICENSE OR - Claw
`(commencing vkh Section 7000) of Division 3 of the Business and REG.NUMBER
Professions.Code,and my license is in full force'andleffect. 3 ��--{{ON - DIBTRICT NO PROCESSED By
• :
_Power Apparatus 8 Large 1{ppliances . --,.. ..
11 - Size& Type HP,KW,KVA,or KVAR {` 50
License.Number Lic.Class ` Up to 1 IncF - FINAL"
C.1
Over 1 to 10 Incl _ DATE, /D 0VALIDATI Q
Contractor,-" Date Over 10 to 50 Incl. ` U
FINAL
❑ I am exempt under Sec.' - _ .Over.50 1o.100.1nc. BY - .W
'
Over 100 68P.C. for this reason - " A, �-
Services,Swbo.,MCC 8 Parielboards- ►' - O Q, ,],5�88 Z
Date: - 0- 200 Amp.Under 600 V
Signature ` 201 - 1000 Amp.Under 600 V - - ,
2939.2A
.p.,� r, Over 1000 Amp. or Over 600 V ... ',
Exemption for Reg.Mamt.Elect. ,s' - O • • •,• • 2' .
SINGLE FAMILY , Temp.Power Pole & Appurtenances _ - - ' I -.- ,3-1.5 '
150
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby-affirm that I am exempt foornthe Contractor's'Ui ease Lawes ,i+ • • -3;1 5 0 �.
for the following reason(Section 7031.5,Business and Professions' Additional Sign Branch-Circuits-
Code):
04. 15'-88
® - Misc.Conduits.&Conductors" - _ �- " ' - - •-;t ._ -
. I,:as owner of the property,will do the work and:the structure
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) _ _ •, ,
and Professions Code). -
CONSTRUCTION LENDING AGENCY - - -'
I' .lendi hereby=affirm that there is a construction 'agency for the -
performance of thework for which this p6heit'is issued(Sec.3097 PERMIT FEE "' 'Sub-Total) - ` - •' - s-
• PLAN CHECKING FEE• - - -- - -
Lender's Name
., .PERMIT ISSUING.FEE
Lender's Address r ' - /1 ,�'•
I certify that I have read this application and state that the above' TOTAL FEE
.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 purposes. -
�� SEEREVERSE FORE%PLANATORV LANGUAGE'
.Signatu of rmicte_� '. 1 1 D .. - .. - ...