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16A666-C66064-601'1 APPUCAMN FOR IYI ELECT CAL PERp\VY� T/IB
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER 7ADDRESS
~
BUILDING AND SAFETY DIVISION D
JOHN A.LAMBIE, COUNTY ENGINEER
WILLIAM A.JENSEN, SUP'TOF BUILDING
# FOR APPLICANT TO FILL IN NEAREST
CROSS ST
PERMIT FEES OWNER !zo
1 T E M NUMBER EACH FEE
OUTLET $ $ MAIL' /' 1
LIGHTS RECEPT. SW, .1O ADDRESSZ,7 3 Q /S I V 0 /'
LIGHTING FIXTURES 10 Q CITY TEL NO , 4 �e
ELEC. RANGES CLO. DRYERS ELECTRICIAN
WATER HEATERS .50 ADDRESS
LEC.SPACE HTRS DISHWASHERS CITY TEL.NO.
RBAGE DISPOSERS AUTO.. STATE
25 LICENSE NO.
WASHERS STA.COOKING UNITS �,ss
MOTORS: OVER INC. H.P DISTRICT NO. GROUP ZONE P
O — 1V2 .25 Z
2 .50 INSPECTION RECORD
2 5 1.00
s — 15 1.50 A ^ l9A 0
15 — s0 2.150 ix
50 — 200 5.00 _ ✓ ujV
SIGNS: NO TRANS. 7
CL
NO. LAMPS ^ i� / In
SERVICE 0.600V 1.00
SERVICE OVER 600V 5.00
MISC.
1./
F
WIRING PERMIT 1.00
FIXTURE PERMIT 1.00
SUPPLEMENTARY PERMIT 50
TOTAL FEE $
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION APPROVALS DATE INSPECTOR'S SIGNATURE
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING CONDUIT
ELECTRICAL WIRING. WIRING
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF FIXTURES it
CALIFORNIA OR THAT I AM THE EGAL OW ER OF THE ABOVE
DESCRIBED RESIDENTIAL PE POWER ,0
SIGNATURE UTILITY CO. NOTIFIED ^Q
OF PERMITTE
#LIDATION' ARTHUR C.VETT.
MO CASH SUPERVISING ELECTRICAL ENGINEER
�'0 9 1 1 5 JUN 2 3 2 D 6.3 5to
WORKERS'COMPENSATION DECLARATION CE-806 10,81 ,�, PPUCAIMN FOR ELECYR�C L PER( T
I hereby affirm that 1 have a certificate of consent to self CE-806G G�1 FOR G�1 Ill`7l1
insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES_, BUILDING AND SAFETY
oi•o certified copy thereof (Sec 3800, Lab C ) 1 r 1
PolicyNo—Company FOR APPLICANT TO FILL IN, JOB G /
❑ Certified copy is herebyf furnished New Residential Bldgs & Pools EACH NO FEE ADDRESS
❑ 1 & 2-Family, S Ft $ _ $ LOCALITY
Certified copy is filed with the county building inspec- Y, q
tion department Multi-family Sq Ft CROSSSST
Dote Applicant Residential Swimming Pools OWNER ORr r
FIRM NAME 01 f
CERTIFICATE OF EXEMPTION FROM WORKERS' MAIL C
Outlets Rec Light -Sw
COMPENSATION INSURANCE ADDRESS)
This section need not be completed If the work involved b First 20 -
( p y Total No Additional CITY &` ��� Tel No� >
the permit is for one hundred dollars($100)or less.) -
I certifythat in the erformance of the work for which this PLAN CHECK
e P APPLICANT
permit is issued, I shall not employ any person in any manner
so as to become subject to the Work C mpensat n Laws , Lighting Fixtures First 20 ADDRESS
Total No Additional
Date f�'�-, �3 Applicant CITY Tel No
Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT 'If, after making this Certificate of
Exemption, you should become subject to the Workers' Range_ Heater D W APPLICANT
Compensation provisions of the Labor Code, you must forth- Oven _ Dryer W M _ ADDRESSS /V� L
with comply with such provisions or this permit shall be Top _ FAU —W H — r
deemed revoked Hood Fan _ Other— CITY -W, Tel No7_,&j -19
LICENSED CONTRACTORS DECLARATION LICENSE OR
I hereby affirm that I am licensed under provisions of Chapter 9 Disp _ Room Air Cond REG NUMBER Class
(commencing with Section 7000) of Division 3 of the Buimess DISTRICT NO PROCESSE BY
and Professions Code,and my license is in full force and effect Power Apparatus 8 Large Appliances �O ^� d
Size &Type HP, KW, KVA, or KVAR V{� O
License Number Lic Class � Up to 1 Incl FINAL U
r Over 1 to 10 Incl DATE �� �� VALIDATION 09
Contractor Date❑ Over 10 to 50 Incl 11--
FINAL
I am exempt under Sec Over 50 to 100 Inc BY r y p e LU
B�&P C for this reason Over 100 h
Date
Services, Swbd , MCC& Panelboards D Z
0 -200 Amp Under 600 V
Signature 201 - 1000 Amp Under 600 V z 7 2 5 8 A
❑ Over 1000 Amp or Over 600 V
Exemption for Reg Maint Elect `} 0 0 0 0 m 2
SINGLE FAMILY Temp Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit I 0 0 1 � 0 0
I hereby affirm that I am exempt from the Contractor's License o its Additional Sign Branch Circuits o a 1 ()
Law for the following reason (Section 7031 5, Business and 0 0 5
Professions Code) I
120 1 -8 3
❑ 1, as owner of the property, will do the work and the Mi Conduits&Conductors
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ D
7044, Business and Professions Code)
CONSTRUCTION LENDING AGENCY I
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued PERMIT FEE (Sub-Total)
(Sec 3097, Civ C )
r
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE ele
Lender's Address -
I certify that I have read this application and state that the TOTAL FEE Vol
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
4eee�nspecfion purposesSEE REVERSE FOR EXPLAidATORY LAIIIGUAGE
re of Date