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76A66C-CE#808 5-61
APPLICATION FOR ELECTRICAL PERMIT
COUNTY OF LOS /ANGELES
DEPARMENT OF COUNTY ENGINEER TAD
NG aj
BUILDING AND SAFETY DIVISION / sJOHN A. LAMBIE. COUNTY ENGINEER
WILLIAM A.JENSEN,SUPT OF BUILDING TY
T
FOR APPLICANT TO FILL IN ST.
PERMIT FEES OWNER
1 T E M. NUMBER EACH FEE MAIL
OUTLE S 5 ADDRES
LIGHTS RECEPT SW. .10 CITY TEL. N
LIGHTING FIXTURES ,10
ELEC. RANGES CLO. DRYERS ELECTRICIA
WATER HEATERS . .50 ADDRESS 7
ELEC.SP CE HTRS. DISHWASHERS ( V
//` CITY NO
GARBAG DISPOSERS/ AUTO.- �7 STATE _
WASHERS STA.COOKING UNITS
,2$ ` LICENSE NO.
MOTORS: OVER INC. H.P. DIST ICT btQ-. GROUP N ESSED B
0— 1/2 .2 5
1/2- 2 .50 INSPECTION RECORD
2— 5 1.00 IL
O
5— 15 1.50 V
ad
15— 50 2.50 0
I--
50— 200 5.00 W
SIGNS:
NO TRANS.
�
NO.LAMPS - z
SERVICE 0-600V 1.00
SERVICE OVER 600V 5.00
misc.
WIRING PERMIT 1.00
FIXTURE PERMIT 100
SUPPLEMENTARY PERMIT .50
TOTAL FEE S
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION APPROVALS DATE INSPECTOR'S SIGNATURE
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINA_N C ES AND .STATE LAWS REGULATING CONDUIT
ELECTRICAL WIPING. WIRING
I HE CERTIFY TH I AM PR PERLY REGISTERED AND/OR
LICENSED AS REQUIRE BY LOS A ELE GO Y AND STATE OF FIXTURES
CALIFORNIA OR THAT HE EGA O OF THE ABOVE
DESCRIBED RESIDENT IA P ERT POWER
SIGNATURE UTILITY CO.NOTIFIED 0/
OF PERMITTEE FINAL 2/1,3/��_• .�C �%���
LIDATION ARTHUR C. VEI-f-
cK Mo CASH SUPERVISING ELECTRICAL ENGINEER
,5 4 1 $-'0-4 .m0v'24 2 D 112,0 '19
RKERS' COMPENSATION DECLARATION CE-806 10/81 APPLICATION FOR ELECTRICAL PERMIT
1-he eb� rm Fhaf;'I ,ha,se a certificate of consent to self CE-806G
ms`ure, 1.
ty�ra certific6te of Workers' Compensation Insurance, COUNTY OFrLOS ANGELES BUILDING•AND SAFETY
r a cerhfted copy thereof (Sec 3800, Lab C )
Policy No Company FOR APPLICANT TO FILL IN JOB /
Cerpfied copy is hereby furnished New Residential Bldgs. & Pools EACH NO FEE ADDRESS
Certified copy is filed with the county building mspec_ 1 &2-Family, Sq. Ft. _ $ — $ LOCALITY (.ze
tion department Multi,-family Sq Ft Tie—� — NEAREST
'CROSS ST l0
Residential Swimming.Pools- .+ •, OWNER OR ---•�/�
Date Applicant 'FIRM NAME 4
r
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw �. MAIL
_ ADDRESS
COMPENSATION INSURANCEPKk
This-section need t bFirst 20
( noe com pleted if the work involved b Y Total No. Addrtion'al CITY - Tel. No
the permit is for one hundred do ,llars (;100)or less.) ,
PLAN CHECK
I certify that in the performance of,the work for which this APPLICANT
permit is-issued, I shall not employ any person in any manner i
,so as-td-become subject to the Workers'Compen bahting Fixtures / First 20 ADDRESS
Total No Additional
�� CITY e No,
]` Date pp Fixed Appliances Not Over 1 HP PERMIT,
NOTICE TO APPLICANT: If, a er making this Certificate of APPLICANT
Exemption, you should 'become'subject to the Workers' Range_ Heater_D W. —
ComperisatFon provisions,of°the Labor Code, you must forth- Oven _ Dryer, W M — ADDRESS
with comply with :such provisions or this 'permit shall.be Top _ FAU W H•
deemed revoked. Hood Fan _Other_ CITY Tel No.
LICENSED-CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 Disp _ Room Air Cond' LICENSE Class.
REG NUMM BER
(commenting with Section 7000) of Division 3 of the Business DISTRICT-NO ZPRSSED BY
Power Apparatus & Large Appliances
13-
and Professions Code,and my license is n full force arid,effect. �1 0
Size & Type HP, KW, KVA, or KVAR / /� U
License Number Lic ClassUp to 1 Incl. DATE f O
Over 1 to 10 Incl VALIDATIO F–"
Contractor- Date Over 10 to 50 Incl
❑ FINAL' W .
I am exempt under Sec, Over 50 to 100 Inc. BY LL
Over 100 z
B.&P.C. for this reason _
Date Services, Swbd , MCC& Ponelboards
0 -'200 Amp Under 600 V
Signature 201 - 1000 Amp Under 600 V
❑ Over 1000 Amp. or Over 600 V 5:2 7,.7 A
Exemption for Red"Maint Eject
SINGLE FAMILY' Temp. Power Pole &Appurtenances # o o e,o o•2
HOME OWNER-BUILDER DECLARATION. Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License :•1'°,° 3 0."7 5
Law for the following reason (Section 7031 5, Business and Additional Sign Branch Circuits
' Prsions Code) °'°'O 3 Q 7 5,�, asowner of the ro ert will,do the work and the Misc. Conduits 8 Conductors/ P e v. 0.8.1 9,t.
- 86
structure is not intended-or offered for sale (Section Other (See Complete Fee Schedule.)_
7044, Business and Professions Code).
-CONSTRUCTION LENDING AGENCY
I hereby affirm that there is'a construction lending agency for
the performance of the work'for which this,permit is i"ssued PERMIT FEE (Sub-Total)
(Sec 3097, Civ C )
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE
Lender's Address
I certify that I have read this application and state that the TOTAL FEE
above information is correct I agree to comply with all County
ordinances and State jaws regulating Electrical wiring, and
hereby authorize representatives to enter upon
the abov - roperty for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date