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7&A"M 011183A 11-49 ,s APPLICATION FOR PERMIT
DEPARTMENT OF BUILDING AND SAFETY ELECTRIC
COUNTY OF LOS ANGELES
WILLIAM J. FOX, CHIEF ENGINEER
FOR APPLICANT TO FILL IN DISTRICT NO. GROUP ZONE PERMIT NO.
ELECTRICIAN f Q. (5 t& C'& //2
RECEIVED BY READY FOR DATE ISSUED
ADDRESS 0 J III Af V Qb it It cr 1 FIRST IN PEC ON
CITY TEL..NO � O601101 2--&-6-0
COUNTY LICENSE NO Y EXPIRES —30 ArO BUILDING /1 SAO �� oto 4. —."%-PERMIT FEES ADDRESS I� /C
Coe
NUMBER I OUTLETS EACH FEE LOCALITY 91
LIGHT dD * NEAREST
CROSS BY.
NSG '
RECEPTACLES 5
FIXTURES s &01 OWNERho'e, A 0)A
WALL SWITCHES 5 MAIL
ELED RANGES 25 ADDRESS
ELEC HEATERS 25 CITY �D Se M LO A of t TEL.. NO
Minn 1 HEREBY ACKNOWLEDGE THAT i HAVE READ THIS
NUMBER OF CIRCUITS INSTALLED
TOTAL APPLICATION AND STATE THAT THE ABOVE IS CORRECT
LIGHT RECEPTACLES AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES
MOTORS AND STATE LAWS REGULATING ELECTRICAL WIRING
NUMBER HORSEPOWER FEE i CERTIFY THAT I POSSESS THE ABOVE VALID LOS
NEW MVD HP DVEII I IND EARN ANGELES COUNTY LICENSE, OR I AM THE LEGAL OWNER
I/2 & LE88 25 OF THE REBIDEN'TI PRS/OPPERTY SCRIBED ABOVE.
%2 2 50 SIGNATURE OF I
2 5 1 Op PERMITTEE
5 is ISO INSPECTION RECORD
15 so 2.50
so 200 Sam
200 s00 loco
SOO 1000 loco Q
OVER 1 OOO 2000 Z
M G SET/FREQ CHANGER-HP 0
WELDERS AC-KVA Q
GENERATORS - KW !, w-id O
TRANSFORMERS - KVA loop
TEMP MOTORS (75% DF DnIG)
MOVED MOTORS (75% or ORIG)
M LSC
SIGNS
TYPE? Q 0 NI NO.TRANS Z OO
TYPE, NO LAMPS APPROVALS /
FOR EACH PERMIT: DATE INBPECTORYB NAME
WIRING mica D CONDUIT
FIXTURES !111.00 b O WIRING
SUPPLEMENTARY d0 FIXTURES
r
POWER,7
TOTAL FEE • UTILITY CO NOTIFIED i
FINALC-
WORKERS'COMPENSATION DECLARATtorl LAW 19/81 APP ATION FORELE TRI PERMIT
1 hereb affl�hat I have a certificate of consent to self CE e06G
insure, a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a ce fied copy thereof (Sec 3800, Lab C )
Policy No Company FOR APPLICANT TO FILL IN JOB
Certified copy is hereby furnishedNew Residential Bldgs 8 Pools EACH NO FEE ADDRESS -wioA
Ar
Certified copy is filed wit cou bu iri 1 &2-Family, Sq Ft S — E LOCALITY✓�/7tion department Multi-family Sci Ft NEAREST ST e ZResidential Swimming Pools CROSSDate Applicant OWNER OR U/&-
FIRM NAME
-M 14M
CERTIFICATE OF EXEMIV 4WVI�
PT N R RKEOutlets Rec�Li ht Sw_ MAIL A
COMPENSATI I SU g ADDRESS AZ1Lodw
(This section need not be com ed If the work involved by First 20
the permit is for one hundred dollars($100)or less) Total No Additional CITY LG Tel
I certify that in the performance of the work for which this PLAN CH
ECK
permit is issued, I shall not employ any person in any manner APPLICANT / qir
so as to become subject to the Workers'Compensation Laws Lighting Fixtures First 20 ADDRESSW)
f'Total No Additional CITY T
Date Applicant Fixed Appliances Not Over 1 HP PERMR I
NOTICE TO APPLICANT If, after making this Certificate of APPLICANT
Exemption, you should become subject to the Workers' Range_ Heater_D W _
Compensation provisions of the Labor Code, you must forth- Oven _ Dryer _W M — ' ADDRESS
with comply with such provisions or this permit shall be Top _ FAU --WH —
deemed revoked CITY T'el No
Hood _ Fan _Other—
LICENSED CONTRACTORS DECLARATION F LICENSE OR
I hereby affirm that I am licensed under provisions of Chapter 9 Disp _ Room Air Cond REG NUMBER Claes
(commencing with Section 7000)of Division 3 of the Business DISTRICT NO PR D BY
and Professions Code,and my license is in full force and effect Power Apparatus&Large Appliances }
Size&Type HP, KW, KVA,for KVAR
License Num er Lic Class__ V
Up to 1 Incl FINAL
LAl1�Nlra (.t+o Over 1 to 10 incl DATE VALIDATION
Contractor DaTe❑ Over 10 to 50 Incl FINAL 11
I am exempt under Sec Over 50 to 100 Inc _BY CJ d
Over 100
B 8P C for this reason ` ti Z
Date Services, Swbd , MCC&Ponelboards ►
0 -200 Amp Under 600 V
Signature 201 - 1000 Amp Under 600 V
❑
Exemption for Reg MaOver 1000 Amp or Over 600 V ,
mt Elect
SINGLE FAMILY Temp Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit - 0 0 0 0 2
1 hereby affirm that I am exempt from the Contractor's License Additional Sign Branch Circuits
Law for the following reason (Section 7031 5, Business and o o (�0Professions Code)
❑ I, as owner of the property, will do the work and the Misr Conduits&Conductors 0 C r
structure is not intended or offered for sale (Section her(See Com tete Fe chedu ) ^
7044, Business and Professions Code) , ( G L.
CONSTRUCTION LENDING AGENCY
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 )
PLAN CHECKING FEE
O��
Lender's Name M
e PERMIT ISSUING FEE
Lender's Address N/A 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 1
hereby authorize representatives of this County to enter upon
the above-mentio a property for inspection purposes
//— �� SEE REVERSE FOR EXPLANATORY LANGUAGE
Sign t eo Permittee —r Date
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