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i6A669 CE-60616/761 APPLICATIO FOR ELECTRICAL PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN JOB p
New Residential Bldgs.&P' Is // EACH NO. ADDRESS
1 &2-Family,Sq.Ft. I�� $ .025 — $ LOCALI UT
Multi-family Sq.Ft. •02 — NEAREST
Residential Swimming Pools 25.00 OWNER OR --�-+
FIRM NAME �Jt
Outlets:Rec Light—Sw. MAIL.
First 20 :50 ADDRESS
Total No. Additional .30 CIT Tel.No.
PLAN.CHECK
APPLICANT
Lighting Fixtures First 20 •50 ADDRESS
Additional .30
Total No. CITY Tel.No.
Fixed Appliances Not O,ver 1 HP PERMIT
Range—Heater—D.W._ APPLICANT �GfC
Oven_Dryer—W..M.— ADDRESS /271
/271
Top _FAU —W.H._ CIT. Tel.N
Hood_Fan. _Other_ LICENSE OR
Dlsp.—Room Air Cond. 2.50 REG.NUMBER, Class
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICA-
Power Apparatus&Large Appliances TION AND STATE T HE ABOVE IS CORRECT AND AGREE.TO
Size&T e HP,KW,KVA,or KVAR COMPLY WITH CO NTY ORDINANCES AND 'STATE LAWS
Yp REGULATING ELECTRICAL IRING.
Up to 1 Inc[. 2.50
I HEREBY CERTIFY .HAT I:AM PRO RLY REGISTERED A DIOR
Over 1 to 10 Incl. 5.00 1 1 LICENSED AS REQUIRE LOS A GE C .UNITY AND ATE OF
Over l0 to 50 Incl. 12.50 CALIFORNIA OR TH AM T LE AL NER O T ABOVE 0
Over 50 to 100 Inc.
25.00 DESCRI ED RESIDE AL PROP Y. 0
Over 100 40.00 FERMI EE A
SIGNA. //
Services DISTRI O. OCE ED BY 2
0-200 Amp.Under 600 V 12.50
201-1000 Amp. Under 600 V 25.00
Over 1.000 Amp.or Over 600 V 50.00 Z
Temp.Power Pole&Appurtenances 10.00. _Y3 y'6 c
Sign with One Branch Circuit 10.00
Additional Sign Branch Circuits 2.06. INSPECTION >
INFORMATION u
Misc.Conduits&Conductors 10.00 ON REVERSE s
Other(See Complete Fee Schedule) SIDE u
Z
5 -24955A
# o 6 o 0 o 2
PERMIT FEE (Sub-Total)
PLAN CHECKING FEE (One-Fourth Permit Fee! Z 2 0 0.'�(ao o 0
PERMIT ISSUING FEE $7.00 0 7
TOTAL FEE > 061
8-79
r
INSPECTION FINALED
date: re-/P—, By �'�+ 6 ®s
WORKERS"I COMPENSATION DECLARATION' s 78-883 10/81 APPLICATION FOR ELECTRICAL PERMIT
CE-806G '
' Itifie�by.affirm,that I have a,certificate-of consent to self insure, + ,
or a,pe ificate rnPwcrkers' Compensation Insurance, or a certified .I I `fl
COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy,t''y�,reof(Se c.3800,Lab.C;)
Policy No. Company FOR APPLICANT TO FILL IN JOB ..�
❑ Certified copy is hereby furnished. New Residential Bldgs.&Pools EACH NO. FEE i ADDRESS ;
Certified copy is filed with the county building inspection 1 &2-Family,.Sq.Ft. $ _ $ LOCALITY
clgp%rtment. Multi-family Sq.Ft. NEAREST
Residential Swimming Pools CROSS.sT
Date Appiican I ,. OWNER O
' FIRM.NAME
CE KATE OF EXEMPTIO FROM RKERS' Outlets:Rec Light S MAIL
COMPENSATION INSURANCE ADDRESS
(This section need not be completed if the work involved by the Q First 20
permit-is for one hundred dollars($100),or less.)
Total No. v Additional CITY Tel.No.
I certify that in the performance of the:work for Which this permit i' PLAN CHECK
is issued, I shall not employ any person in any manner so as to, APPLICANT
become subjedt to the Workers''Compensation Laws. Lighting Fixtures First 20 7 ADDRESS
Additional,
Total No. CITY Tel.No
Date Applicant I
Fixed Appliances Not Over 1 HP PERMITTel.NoP/-J J1
NOTICE TO APPLICANT. If, after making this Certificate of APPLI
Exemption,,you should become subject to the Workers'Compensation Range_ Heater_ D.W. j
provisions.of the.Labor'Code,you must forthwith comply with such Oven ._ Dryer_ W.M._. ADDR ®+ /
provisions or this pbrinit shall be deemed revoked. Top FAU W.H. _
i22"Aft
CITY .
LICENSED CONTRACTORS DECLARATION Hood — Fan � Other_
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. Room Air Cond. LIC NSE OR Class.
(commencing with Section 7000)of Division 3 of the-Business and I REG.NUMBER
Professions Code,and my license is(n full force and effect. Power Apparatus&Large Appliances i DISTRICT. . O PROLES BY
r I Size&Type HP,KW,KVA,or KVAR
License Number - �' 3, /� Lic.Class— 3 Up to 1 Incl.. FINAL p, .,
' Contractor .�/�(/"• e Over 1 to 10 Incl. DATE J VALIDATION
Over 10 to 50 Incl. FINAL �j
❑ I am exempt under Sec. Over 50 to 100 Inc. BY / yJ
Over 100 p-
B&P:C.for this reason Z
Services,Swbd.,MCC&Panelboards
Date: 0-200 Amp.Under 600 V
Signature 201. - 1000 Amp.Under 600 V
Over.1000 Amp..or Over 600 V
❑ Exemption for Reg.Mafnt.Elect.
SINGLEFAMILY Temp.Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch.Circuit ' /�•�•
I hereby affirm that I am exempt from the Contractor's License Law Additional Sign Branch Circuits
for the following reason(Section 7031.5,Business and Professions
Code): i 3M7 20.75
Misc.Conduits&-Conductors
El1,as owner of the property,will qo the work and the structure 'r �.• •-
is not intended or offered for sale.(Section 7044, Business Other(See Complete Fee Schedule) _ ,gyp 5
and Professions Code). I poll-
CONSTRUCTION
T'10/���/. cgss� �.P
CONSTRUCTION LENDING AGENCY i MM 20.Z
I hereby affirm that there is a construction lending agency for the
performance of the work for which this permit is issued(Sec.3097, PERMIT FEE (Sub-Total). 100
Civ.C.).
PLAN CHECKING FEE
Lender's Name
• PERMIT ISSUING FEE � �*A®a��
Lender's Address //��
I.certify'that I have 'read t pplication and state.that the above I TOTAL FEE. j V
information is correct.I e to comply with all County ordinances
and State laws regu i lecthcal Wiring, and hereby authorize
representatives of ounty to enter upon the above-mentioned
propert for ins a ur ores. ,SEE REVERSE FOR EXPLANATORY LANGUAGE
i
Signature of Permirtee 7 Date