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°"°°s .°' APPLICATION FOR ELECTRIC PERMIT 1
COUNTY OF LOS ANGELES ON
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION ADDRESS
JOHN A. LAMBIE. COUNTY ENGINEER
WILLIAM A.JENSEN.SUPT OF BUILDING LOCALITY /
FOR APPLICANT TO FILL IN NEAREST
P HMLT FEES CROSS ST.
G
ITEM NUMBER OWNER ed i99
EACH FEE MAIL
OUTLET 6 $ ADDRESS
LIGHTS RECEPT.� SW. �� .10 °/ -
LIGHTING FIXTURES .' .10 1341 CITY TEL.NO.
ELEC.RANGES CLO.DRYERS ELECTRICIAN
WATER HEATERS .50 ADDRESS FX39P ab d/ •B V
ELEC.SPACE HTRS. DISHWASHERS CITY dw TEL.NO.,*/
GARBAGE DISPOS AUTO.. STATE ��jj
WASHERS STA.COOKING UNITS .25 LICENSE NO. IG Id
MOTORS: OVER INC H.P. DISTRICT NO. GRO P I ZONE I Pwropmommi CESSED BY
0— 1/2 .25
24
1/2— 2 .50 INSPECTION RECORD
2— 5 1.00 e2. ..&o
s— Is 2.50
1s— so 2.50.
50-200 15.00
NO.TRANS.
SIGNS: NO.LAMPS Q N L mi-TIC ,A cS sV O^
SERVICE 0-600V 1.00 oG
t SERVICE OVER 600V 5.00 �^ 1-27%9CM} PJ-r T3 C,7�1QOtJh�
MISC. L4,j I Qr L'r !� T / I /�. (fI Y3r
WIRINGPERMI.T 1.00 L®®
FIXTURE PERMIT 1.00 ! 0
SUPPLEMENTARY PERMIT .50 O TPC a L-9•/Ar FIA7. /ly
TOTAL FEE
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATIO APPROVALS DATE INSPECTOR'S SIGNATURE
AND STATE THAT THE ABOVE 16 CORRECT AND AGREE TO COMPL
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATIN CONDUIT �Irr
ELECTRICAL WIRING. WIRING
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND ATE OF FIXTURE
CALIFORNIA OR THAT I THE EGA OWN OF E ABOVE
G DESCRIBED RESIDENTIA P PE PO R'
SIGNATURE UTILITY CO.NOTIFIED
OF PERMITTEE FIN& / 4.M I04FC `�
�P DATION AR HUR C.VETT.
CK MO CASH SUPERVISING ELECTRICAL ENGINEER
_,00 6 0 3 VAY 2 A ^,9.4 5
WORKERS'COMPENSATION DECLARATION I CE-806G
10./81 APPLICATION FOR ELECtRICAL PERMIT
.� CE-806G
�, 3r�/i t to I ha"ve a certificate.of consent to self insure,
or a certificate of Workers' Compensation Insurance, or a certified COUNTY OPLOS ANGELES BUILDING AND SAFETY
copy thereof(Sec.3800;Lab.C.)
-Policy-No:-- Company FOR APPLICANT FO FILL IN JOB $
❑ Certified copy is hereby furnished.. EACH NO. FEE ADDRESS
- New Residential Bldgs.A Pools p�
;❑ Certified copy is filed with the 'county building1 &2-Family;Sq.Ft $ $ LOCALITY �. O L -
inspection _
department. Multi family Sq.Ft. — NEAREST
Residential Swimming Pools OWNERROSS S R
Date Applicant, � OWNER ORED
-
l' FIRM NAME G
CERTIFICATE OF EXEMPTION FROM WORKERS' (�j MAIL
Outlets:Rec Light
- - COMPENSATION INSURANCE ADDRESS
(This section need not be completed if the work involved by the � � Firstt 2 —20 CITY Tel.Nopp'
permit Is for one hundred dollars($'100)'or less:) Total No. L=am Additional,'. .,
I.certify that in the performance of the•work for which this permit PL-N CHECK
APPLICANT
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 ADDRESS
Total No._ Additional CITY Tel.No.
DAM Applicant ' Fixed Appliances Not Over 1 HP
NOTICE TO APPLICANT: If; after making this Certificate of PERMIT
.Exemption,you should become subject to.the Workers'Compensation Range_ Heater_ D.W. _ APPLICANT
provisions of the Labor Code,you must forthwith comply with such Oven _. Dryer_ W.M._ ADDRESS
provisions or this permit shall be deemed revoked. Top FAU _ W.H. _
LICENSED CONTRACTORS DECLARATION Hood Fan OtherCITY Tel.No:
— _
I'hereby affirm that I am licensed.under provisions of Chapter 9 LICENSE OR
Disp. — Room Air Cond. REG.NUMBER Class.
(commencing with Sedtion 7000)of Division y3 of the Business and
-Profession's.Code,and my license is in full force and effect. DISTRICT NO. SED BY
'Power Apparatus&:Large Appliances ,
Size&Type HP,KW,KVA,or KVAR � O
License.Number Lic.Class. Up to 1 Incl. FINAL (�
�. Over 1 to 10 Incl. DATE ✓� VALIDATION
Contractor Date Over 10 to 50 Incl.
❑ I am exemi-pt der Sec. Over 50 to 100 Inc. FIN
BY a
B.&P.C..for this reason Over 100
Services,Swbd.,MCC&Panelboards ® Z
Date: 0-200 Amp.Under 600 V
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 2 ti
HOME OWNER-BUILDER DECLARATION Sfgn fC with One Branch Circuit di
I hereby affirm that I am exempt from the Contractor's License Law T.A
for the following reason(Section 7031.5,Business and Professions Additional Sign Branch Circuits. �n
Code): , ' .. . 3M7 32 000
Misc.Conduits&Conductors
1� I,as owner of the property,will do the work and the structure 1. 1 ITM(See Complete:Fee Schedule)
is not intended or offered for sale (Section 7044, business ► TOTAL 32.00
and Professions Code). , - CHECK 32o00
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is,a construction lending-agency for the a00
performance of the work for which this permit is issued(Sec.3087, PERMIT FEE (Sub Total)
Civ.C.).
PLAN CHECKING FEE, �-1=1
7/W89
Lender's Name PERMIT ISSUING FEE 1 1 °AM o��
Lender's Address ^n
I certify that 1 have read this application and state that the.above TOTAL FEE GJV
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
propert tnspectioi purpo es. ,
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signatu a of Per ittee Date