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76A663-CE806 rO-61 APPLICATI N FOR ELECTRICAL PERMIT
COUNTY OF LOS ANGELES
DEBPARTMENT OF COUNTY UILDING AND SAFETY DIVISION ADDRESS C - ,4S BUILDING Tv�/'_S
JOHN A. LAMBIE, COUNTY ENGINEER
WILLIAM A.JENSEN, SUPT OF BUILDING LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST. /
I T E M NO. EACH FEE q
OUTLETS: Rsr 20) $2O $ �y OWNER
LIGHTS RECEPT. SW. (�� MAIL
OUTLE S: (ADD'L UNITS) .1O D ADDRESS 111Z' G
LIGHTS RECEPT. SW. '7'� Q
LIGHTING FIXTURES: (FIRST 20) .2p CITY'7-
LIGHTING TEL.NO. / C
J
LIGHTING FIXTURES: (ADDITIONAL) .10 -ELECTRICIAN
RANGES CLO.DRYERS WTR.HTRS. 1.00 ADDRESS t Q 1"3
/ -P/,3I op
GARB.D19P. STA.COOK � TEL.NO. Q u
CITY
DISHWASH. AUTO.-WASH. STATE /��`j/ /i
SPACE HTRS. STA.APP.(+h H.P.MAX.) ,50 LICENSE NO. /(G 6 c
MOTORS: OVER NOT OVER H.P. DISTRICT NO. GROUP ZONE PROCESSED BY
0 1 1.00 S, �' � - 2 ' - 3
1 3 1.50INSPFEYION RECORD
r
3 8 2.00 p
V
8 15 2.50 '
15 50 3.00 O
50 100 5.00 V
W
D_
SIGNS: NO.TRANS. H
NO.LAMPS
SERVICE 0.600V-NOT OVER 200A 1.00
SERVICE 0.60OV-OVER 200 A. 2.00
SERVICE OVER 600V 5.00
MISC.
PERMIT ISSUING FEE 2.00 0
SUPPLEMENTA MIT ISSUING FEE 1.00
TOTAL FEE
1HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION 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
ELECTRICAL WIRING. WIRING
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF FIXTURES
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENT ROPERZY. % POWER
/!
SIGNATURE f;; UTILITY CO.NOTIFIED1 I
OF PERMITTEE c� J
FINAL
LIDATION ARTHUR C. VEIT
SUPERVISING ELECTRICAL ENGINEER
CK MO CASH
Cc,
AV-0614�J JM22 2 0 10.2 0, q
WORKERS'COMPENSATIONDECLARATION CE-806G (2-80)
CAPPLICATION FOR ELECTRICAL PERMIT
' CE-806
I .Iiereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY
insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec. 3800,Lab.C.)
70-7 FOR APPLICANT TO,FILL IN JOB -
Policy No.% Company ^SYA✓-l�• � Al-1 - ADDRESS
New Residential Bldgs.&Pools EACH NO. FEE l
EA Certified copyis hereby furnished.. 1 &27Family,Sq. Ft. $ — $ LOCALITY 7 �� r
Multi-family Sq.,Ft. — NEAREST
❑ Certified copy is filed with the county building inspection CROSS ST
-Residential Swimming Pools
department. " OWNEROR
FIRM NAME / JL
Date ApplicantOutlets: Rec.—Light—Sw. \' _ ADDRESS .SS
First 20,
CERTIFICATE OF EXEMPTION FROM-WORKERS' ) Total No. Additional CITY /b/ Tel No. �`_9 9,S/ }
COMPENSATION INSURANCE PLAN CHECK a
APPLICANT 0
(This section need not be completed if the work'involved
Lighting Fixtures First 20
by-the permit is for one hundred dollars ($100) or less.) , ADDRESS
Additional � .
Total No.
I certify that in the performance of the,work for which this - Fixed AN
Not Over 1 HP CITY Tel No. 0.
permit is issired, I shall not employ any person in any manner PERMIT U
so as to become subject to the Workers' Compensation Laws. Range_ Heater D.W. _ APPLICANT W
Oven _ Dryer.—W.M. ADDRESS / to
Date A licant Top _ FAU W.H.._ _ Z
P.P Hood Fan _'Other_ CITY �yLC Tel No.
NOTICE TO APPLICANT: If, after making this Certificate of Disp. Room Air Cond._ LICENSE OR
Exemption, you should become subject to the Workers' REG. NUMBER Class
Compensation provisions.of the Labor Code, you must forth- Power Apparatus& Large'Appliances DISTRICT NO. PROCESSED BY
with comply with such provisions or this permit shall be Size&Type HP,KW,KVA,or KVAR
deemedyevoked. Upto1 Incl. ' y
Over 1 to 10 Incl. FINALDATE
LICENSED CONTRACTORS DECLARATION Over 10 to 50 Incl.' VALIDATION
I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. FINAL
BY
9 (commencing with Section 7000) of Division 3 of the Busi- Over 100
_mess and Professions.Code, and my license is in full force and
effect. Services
License Number Lic.Class' 0-200 Amp. Under 600 V
201-1000 Amp. Under 600 V
Contractor Date Over 1000 Amp:or Over 600 V
HOME OWNER-BUILDER DECLARATION Temp.Power Pole&Appurtenances
I hereby affirm that I am exempt from the Contractor's Sign with One Branch Circuit U b 2 A
License Law for the following reason (Section 7031.5, Busi- Additional Sign Branch Circuits'
ness and Professions Code): ;-
Misc.Conduits& Conductors 2 •1'• 1'9.50
I, as owner of the property, will do the work and the Other (See*Complete Fee Schedule)—
structure is not intended or offered for.sale (Section •s+o '
7044, Business and Professions Code). 1 9,5 0=
v .
CONSTRUCTION LENDING AGENCY _
I hereby affirm that there is a construction'lending agency l7 G 0 6'—g 1
for the performance of the work for which this permit is PERMIT FEE (Sub-Total) �Z Sfl
issued(Sec. 3097,Civ.C.).
Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee)
Lender's Address PERMIT ISSUING FEE 1
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 laws regulating Electrical wiring, and
hereby authorize representatives of this County to enter upon
tabove-mentioned pro y'for inspection purposes.
SEE'REVERSE FOR EXPLANATORY LANGUAGE
ti
Signature of Pe4nitt'e Date