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A653-C2806 4-80 APPUCATION FOR, ELECTRICAL PERMIT �
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER ;.BUILDING
BUILDING AND SAFETY DIVISION ADDRESS G�
JOHN A.LAMSIEr COUNTY ENGINEER
WILLIAM A.JENSEN,'SUP-T OF BUILDING LOCALITYt
FOR APPLICANT TO FILL IN 'NEARESTS ST
•CROS
PERMIT FEES• OWNER `
ITEM NUMBER EACH FEE 1 MAIL j
OUTLETS: $ $ ADDRESS /
LIGHTS RECEPT. SW. .10
'CITY ' TE NO'
LIGHTING FIXTURES .f0
ELM.RANGES CLO.DRYERS :.ELECTRICIAN
W A,T E R HEATERS .80 ADDRESS'
RISC.SPACE HTRS. DISHWASHERS CITY TEL.NO. .
GARBAGE DISPOSERS AUTO.- _ -STATE `1
LICENSE NO. K
WASHERS STA.COOKING UNITS .28 ... _: •,,,:. �
i
MOTORS: OVER INC. P. DI ICT GR P Z.N P
O — 1/s .28
cd
1/a — 2 .80 INSPECTIO ECORD
2 — 8 1.00 Dom.
5 — 1g 1.80 U
Is — 80 2.80 '
O
SO— 200 8.00 -
W
NO TRANS.
SIGNS: r N
NO.LAMBS
Z
SERVICE 0.600V 1.00
SERVICE OVER 600V 8..00
MISC.
WIRING PERMIT 1.00
FIXTURE PERMIT 1.00'
SUPPLEMENTARY PERMIT ,80
TOTAL FEE slt
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION APPROVALS DATE INSPECTOR'S SIGNATURE
AND STATE THAT THE ABOVE 18 CORRECT AND AGREE TO COMPLY '•
WITH. ALL COUNTY ORDINANCES AND STATE LAWS RBGULATING . CONDUIT •+'�
ELECTRICAL WIRING. ` WIRING
1 HEREBY CERTIFY T I AM PROPERLY REGISTERED'AND'/CR -OR -
LICENSED A8 REQUI BY LOS AN COUNTY ND STATE OF FIXTURES
!�
CALIFORNIA ORT T AM OWN6 F THE ABOYE
DESCRIBED RESID L E . " POWER. -
SIGNAT II. UTILITY CO.NO77
TIFIED. s
OF PE 1 a a FINA
VALIDATrf ARTHUR LEC .
CK MO SUPERVISINGNG ELECTRICAL ENGINEER
;ill 7 1 7,8 FEB 17 2 p 1 .2 0 � .
L'' _ _.
WORKERS'COMPENSATION DECLARATION YO.0019DPW 3/87 APPLICATION FOR ELECTRICAL PERMIT O
I hereby affirm that I have a certificate of consent to self 7d4663
insure, or a certificate of Workers'CdrtrpeQCE-806Gsati6n Inaurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
or-a certified copy thereof(Sec. 3800, Lab. C.)
Policy No. Company FOR APPLICANT TO FILL IN JOB QSZ� pug-' Za_!;. ®.
0 Certified copy is hereby furnished. New Residential Bldgs. &Pools EACH NO. FEE ADDRESS
Certified co is filed with the count building inspec- 1 &2-Family, S Ft. ZO $ — $ LOCALITY Clr-y O �/✓) L� �/T
PY � Y 9 P Y. q•
NEAREST �(
tion department. Multi-family Sq. Ft. CROSS ST. IreSTA AVb,
Residential Swimming Pools OWNER O
Date Applicant FIRM NAME rVLJ
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec i ight�Sw� MAIL
COMPENSATION INSURANCE v2d ADDRESS P L
(This section need not be completed IF the work Involved by eta First 20 CITY
the permit is for one hundred dollars($100)or less.) Total No.�A�-- Additional Al. No.
S �2 f/U�1 44-899
=CANT
�
I certify that in the performance of the work for which this APPLICANT �V C S f. ✓!
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 G ADDRESS 7f S /ALU '4VC
����' Additional
Date Applicant Total No._ir CITYr/VQ ,R / /4ie Tel. NIV )s,��
NOTICE TO APPLICANT: If, after making this Certificate of Fixed Appliances Nof O 'r 1 HP PERMIT �9 /
Exemption, you should become subject to the Workers' Range Heate D.W. APPLICATION(/ 41IN 9A
Compensation provisions of the Labor Code, you must forth- Oven Dryer..W.M. ADDRESS
T
with comply with such provisions or this permit shall be Top FAU W.H.
deemed revoked. CITY Tel. No.
Hood � Fan —Other—
LICENSED CONTRACTORS DECLARATION Dis 30 — LICENSE OR
I hereby affirm that I am licensed under provisions of Chapter 9 p Room Air Cond. REG. NUMBER Class.
(commencing with Section 7000)of Division 3 of the Business Power Apparatus&Large Appliances DISTRICT NO. ED BY d
and Professions Code,and my license is in full force and effect.
Size&Type HP, KW, KVA, or KVAR Q� Q
License Number Lic. Class -! w U
Up to 1 Incl. FINAL ,, s,
Contractor Date Over 1 to 10 Incl. DATE t VALIDATION cc
aOver 10 to 50 Incl. FINAL F–
I am exempt under Sec. Over 50 to 100 Inc. BY W
B.&P.C. for this reason Over 100 0-
Services,
Services, Swbd., MCC&Ponelboardsp 10. U)
Date: 0-200 Amp. Under 600 V o 410 Z
Signature 201 - 1000 Amp..Under 600 V
Exemption for Reg. Maint. Elect. Over 1000 Amp. or Over 600 V
SINGLE FAMILY Temp. Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION y
ACCT
A&
hereby affirm that I am exempt from the Contractor's License Sign with One Branch Circuit AC4 I e va
Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits �_
Professions Code): 3307 140.6]
I, as owner of the property, will do the work and the Misc. Conduits&Conductors 1 ITEMS
6 `structure is not intended or offered for sale(Section 7044, Other(See Complete Fee Schedule)_ , TO Th 140. 60
Business and Professions Code).
CONSTRUCTION LENDING AGENCY CHECK 14101.60
1 hereby affirm that there is a construction lending agency forf{ �1��
the performance of the work for which this permit is issued PERMIT,FEE (Sub-Total) oC-0
(Sec. 3097, Civ. C.).
PLAN CHECKING FEE Q - ►1 1! ,.79_
Lender's Name PERMIT ISSUING FEE �� .-� 7 �r
Lender's Address / r^ 7793181 AHIP26
� ,�
�
I certify that I have read this application and state that the 0 1�TOTAL
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
the bo -mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Sign'ure of Pe ittee ate b ®s