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OBS-5A 3.59 FOR OR ELECT■ IC PERMIPERMIT �.
.SA
DIVISION OF BUILDING AND SAFETY - -
Deportment of County Engineer 'f
County of Los Angeles BUILDING
WM.J. FOX. COUNTY ENGINEER ADDRESS
CASSATT D. GRIFFIN. SUPT OF BUILDING
c � i
LOCALITY
FOR APPLICANT TO FILL IN NEAREST
PERNIIT FEES CROSS ST.
NUMBER EACH FEE OWNER
LIGHT OUTLETS
MAIL
RECEPTACLES ADDRESS
WALL SWITCHES _
TOTALOUTLETS 5¢ S CITY TEL NO
ELEC RANGES 25
ELECTRICIAN ' �7
ELEC HEATERS 25 ADDRESS i
i
KW EA TEL
FIXTURES 5LICENSE NO. 'q i'
NUMBER OF LIGHT CIRCUITS - DISTRICT NO. GR�L1P N,F� READY FOR INSPECTION
NUMBER OF RECEPTACLE CIRCUITS / I I /�7],
MOTORS
NUMBER HORSEPOWERFEE INSPECTION RECORD
NEW MVD HP OVER INC EACH
I/2 I4 LESS $ .25
1FL 2 50
2 5, 1 00
5 15 1 1 50
15 50 2 50
50 200 500
misc.
NO SIGNS NO TRANS
NO SIGNS NO LAMPS
FOR EACH PERMIT' _
WIRING $1 00 -
FIXTURES $100
SUPPLEMENTARY 50 APPROVALS
TOTAL FEE g J1 DATE INSPE TORS SIGNATURE
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CONDUIT
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING WIRING
ELECTRICAL WIRING.
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR FIXTURES
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF -
CALIFORNIA OR THAT I' AM THE LEGAL OWNER OF'THE ABOVE POWER
DESCRIBED RESIDENTIAL P PERTY. J
SIGNATURE G� UTILITY CO. NOTIFIED
1
OF PERMITTEE I '�,
FINAL
WILLIAM J.FOX, COUNTY EN'w".PER - VALIDATION A. C.VEIT,CHIEF ELECT. INSPECTOR
tcog 1 3 � .`° AUG 13 2 1 .2 5
WORKERS' COMPENSATION DECLARATION 20-0019 DPW 3/87
76AW APPLICATION FOR ELECTRICAL PERMIT
I hereby gfEirm that I have a certificate of consent to self CE-806G
it)stire,••or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
or q certified copy thereof (Sec"N 3800, L b C )
1
PoliCyo�3W�lllL�L�ompany �j i I'!1 FOR APPLICANT_TO FILL IN JOB '
❑Certified copy is hereby furnished New Residential Bldgs & Pools EACH NO FEE ADDRESS
Alt
Certified copy is filed with the county buildm s c- 1 & 2-Family, Sq Ft - $ _ $ LOCALITY
/'�Ttion nde artm nt Multi-family Sq Ft NEAREST l
CROSS S
Residential Swimming Pools OWNEROR J �Av
Date Applicant M! /V;
,,,,``� //////��//��� /� FIRM NAME
ERTIFICATE OF EXEMPTION FROM WORKERS' Outlets Rec�Lighty�/-Sw ZZ ,,n MAIL
COMPENSATION INSURANCE l First 20 D [� ADDRESS
(This section need not be completed if the work involved by Total No Additional 1 60 CITY Tel No
the permit is for one hundred dollars ($100)or less.) PLAN CHECK i
I certify that in the performance of the work for which this APPLICANT z
permit is issued, I shall not employ any person in any manner �Q
so as to become subject to the Workers'Compensation Lbws Lighting Fixtures First ADDRESS �� P
Addittional IF
Total No CITY Tel No Gia -orb
Date Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT If, after making this Certificate of APPLICATION
Exemption, you should become subject to the Workers' Range— Heater—D W
Compensation provisions of the Labor Code, you must forth- Oven Dryer -L W M ADDRESS
with comply with such provisions or this permit shall be Top FAU —WH — 3 / C
deemed revoked Hood Fan1-Other—
/ CITY Tel No
LICENSED CONTRACTORS DECLARATION LICENSE OR
.Disp Room Air Cond _ REG NUMBER Class
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000)of Division 3 of the Business Power Apparatus & Large Appliances DISTRICT NO PR SSED BY d
and Professions Code,and my license is in full force and effect ��'/� 0 /_Ik_j
Size &Type HP, KW, KVA, or KVAR
License Number Lic Class_ Up to 1 Incl FINAL U
DATE
Ce�ig►1- /'( Date S( Over 1 to 10 Incl �'Q -Z -�( VALIDATION O
Contractor FINAL Over 10 to 50 Incl F-
I
U
❑
I am exempt under Sec Over 50 to 100 Inc BY LlJ
B&P C for this reason Over 100 t1
/ �A�mo.
CC& Panelboards U)
Date Q Z
Under 600 V �°�
Signature Under 600 V
❑
Exemption for Reg Maint Elect Over 1000 Amp or Over 600 V
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Temp Power Pole &Appurtenances
I hereby affirm that I am exempt from the Contractor's License Sign with One Branch Circuit;
Law for the following reason (Section 7031 5, Business and Additional Sign Branch Circuits _
Professions Code) :=1= °'=4=
❑ LES'I, as owner of the property, will do the work and the Misc Conduits&Conductors i �i�-''''
structure is not intended or offered for sale(Section 7044, Other (See Complete Fee Schedule)_ , ',j H a1� f0
Business and Professions Code)
CONSTRUCTION LENDING AGENCY _H C)4 °W1
I hereby affirm that there is a construction lending agency for �`(-lf.1 i�i-
the performance of the work for which this permit is issued PERMIT FEE (Sub-Total)
(Sec 3097, Civ C )
Lender's Name
PLAN CHECKING FEE
PERMIT ISSUING FEE /
Lender's Address
rill
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 of this County to enter upon
the above-mentioned proA;fopection pur oses '
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permit ee DatU ( Os