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76ABaS-ceao/4-60 APPLICATION FOR ELECTRICAL PERMIT 'I
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY.ENGINEER rB=UlLDlNGBUILDING AND SAFETY DIVISION JOHN A.LAMBIE,COUNTY ENGINEERWILLIAM A.JENSEN. SUP'TOF BUILDING OCALITY
FOR APPLICANT TO FILL IN NEAREST
CROSS ST
PERMIT FEES
OWNER
1 T E M NUMBER EACH FEE MAIL
OUTLETS: S $ ADDRESS
LIGHTS RECEPT. SW. to
LIGHTING FIXTURES 10 CITY EL N
ELEC.RANGES CLO. DRYERS ELECTRI AN
WATER HEATERS .50 ADDRESS'S"' OL-4 �
ELEC.SPACE HTRS. DISHWASHERS CITY TEL.NO. c 1"Y Q
GARBAGE DISPOSERS AUTO.. STATE [I
WASHERS STA.COOKING UNITS ,23 LICENSE NO. 3 -�--
MOTORS: OVER INC. H.P. I DIS CT OUP ONE P SSED BY
0 — 1/2 .25
Va — 2 .50 INSPfCTION RECORD
2 — a >-
1.0o Q,
iso O
V
is — 50 2.50
Iso — 200 5.00 ri
SIGNSS l NO TRANS. N
NO. LAMPS
Z
SERVICE 0.800V 1.00
SERVICE OVER 800V 5.00
MISC.
WIRING PERMIT 1.00
FIXTURE PERMIT 1.00
SUPPLEMENTARY PERMIT .50
TOTAL FEE s
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATIONL
VALS DATE INSPECTOR'S SIGNATURE
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING /
ELECTRICAL WIRING. /
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR
LICENSED A8 REQUIRED BY LOS ANGELES COUNTY AND STATE OFCALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVEDESCRIBED RESIDENTIAL ROPERTY. ♦SIGNATURE ( � , � . NOTIFIEDOF FERMITTE j
VALIDATI AR HUR C.VETT.
CK Mo CAB SUPERVISING ELECTRICAL ENGINERR
-'
(1..,1 7.
a 4 8 8 0.0r Aml t(. 2D 2.0 Q 10,
i
WORKERS'COMPENSATION DECLARATION CE-806 to/Bl APPLICATION
/k TION FOR ELECTRICAL
1 PERMIT
I hereby affirm that I have a certificate of consent to self CE-8066 �1 r M 1 f 1� G Gtr 1 1� /'1L RI1/�
insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified copy thereof (Sec. 3800, Lab. C.)
Policy No. Company FOR APPLICANT TO FILL IN JOB
Certified co is hereby furnished. PEACHNO. FEEADDRESSPY Y New Residential Bldgs. 8 Pools1 &2-Famil S Ft. =
$ LOCALITY,,?.—, p.
Certified copy is filed with the county building inspec- Y• q•
tion department. Multi-family Sq. Ft. NEAREST
CROSS T. 1 '
Date Applicant Residential Swimming Pools FOIRM NAME , P t
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw._ MAIL ?
COMPENSATION INSURANCE First 20 ADDRESS r• ., 04 f-
(This section need not be completed If the work involved by Total No. Additional CITY r,,,JhNcl.'�
the permit is for one hundred dollars($100)or less.) 6 PLAN CHECK t
I certify that in the performance of the work for which this APPLICANT
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensatioa.Laws. Lighting Fixtures First 20 ADDRESS
Additional
L 1 ? Total No. CITY Tel. No.
Date /f ,4,`Applicti10 ' f Fixed Appliances Not Over I HP PERMIT
NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT w+',r r,i t
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 'i '• , "_� r. .« �, .! };1` �jj
with comply with such provisions or this permit shall be Top _ FAU —W.H. --
deemed revoked. CITY ' , 2 Yro r r:: _? Tel. No.,:r iY
LICENSED CONTRACTORS DECLARATION Hood _ Fan —Other—
LICENSED E OR
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. Room Air Cond. REG. NUMBER Class.`.� �1; ' !
(commencing with Section 7000) of Division 3 of the Business DISTRICT NO. PROCESSED BY
and Professions Code,and my license is in full force and effect. Power Apparatus& Large Appliances y✓^ Ct
Size &Type HP, KW, KVA, or KVAR i �% (` U
License Number Lic. Class U to 1 Incl. FINAL W
l� Over 1 to 10 Incl. ai DATE LL
1Contractor Date VALIDATION
Over 10 to 50 Incl FINAL }
OG
I am exempt under Sec. Over 50 to 100 Inc. BY Q
B.&P.C. for this reason Over 100
O
Services, Swbd., MCC & Ponelboards ► C
Date: 0 -200 Amp. Under 600 V W
Signature 201 - 1000 Amp. Under 600 V
Over 1000 Amp. or Over 600 V
Exemption for Reg. Maint. Elect.
SINGLE FAMILY Temp. Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I(ereby affirm that I am exempt from the Contractor's License Additional Sign Branch Circuits
Law for the following reason (Section 7031.5, Business and
Professions Code):
I, as owner of the property, will do the work and the Misc. Conduits&Conductors 0 24 t , A
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)—
sx: �,rt
p 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY 'i iA 'Tn
11
hereby affirm that there is a construction lending agency for t
th6 performance of the work for which this permit is issued PERMIT FEE (Sub-Total)
(4c. 3097, Civ. C.).
PLAN CHECKING FEE °A
Lender's Name
PERMIT ISSUING FEE ✓ + '
Lender's Address
1 certify that I have read this application and state that the TOTAL FEE j
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 above-.mentioned gwperty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
�; ter`
Signature of Permittee Date