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MASES-CE806 8-62 APPLICATION FOR ELECTRICAL PERMIT
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEERB <UILDING "'.
BUILDING AND SAFETY DIVISION ADDRESS i4 7i L.. c
JOHN A. LAMBIE, COUNTY ENGINEER
WILLIAM A.JENSEN,SUP'T OF BUILDING LOCALITY
NEAREST
FOR APPLICANT TO FILL 1N CROSS ST. ,/J
RECEPT. TOTAL NO, EACH FEE ,
dguLIGHT y" OUTLETS FIRST 20 $20 S O OWNER
MAIL %
ADDIL
SWITCH.
a7 •�a OVER 20 .10 ADDRESS 4.e,m
TOTAL CITY G TEL.NO. 9 4Z
LIGHTING 1 FIRST 20 .20
FIXTURES 1 AOO'L OVER 20 10 ELECTRICIAN
RANGES CLO.DRYERS WTR.HTRB. 1..00 ADDRESS
GARB.DISP. STA•COOK CITY TEL.NO.
DISHWASH. AUTO.-WASH. STATE
SPACE HTRS. STA.APP.(Va H.P.MAX.) .50 LICENSE NO.
MOTORS:. OVER NOT OVER H.P. DIST CT O. 1 GROUP NE FWA3pCESSED B
O 1 1.00 .
1 s 11.50 INSPECTION RECORD
s 5 2.00 6
8 15 2.50 4
15 50 5.00 ff }
a
50 100 5.00 O
U
SIGNS. NO.TRANS.
NO.LAMPS O
SERVICE 0.600V-NOT OVER 200A 1.00
SERVICE 0.600V-OVER 200 A. 2.00 d
N
SERVICE OVER 600V 5.00 ?
MISC.
PERMIT ISSUING FEE 2.00
SUPPLEMENTARY PERMIT ISB.UING FEE 1.00
TOTAL FEE r$ OD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION APPROVALS DATE INSPECTOR'S SIGNATURE
AND STATE THAT THE ABOVE 18 CORRECT AND AGREE TO COMPLY CONDUIT ' y �P11
WITH ALL-COUNTY ORDINANCES AND STATE LAWS REGULATING
ELECTRICAL WIRING. WIRING A
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED. ANO/OR per•
LICENSED AS REQUIRED BY LOB ANGELES COUNTY AND STATE OF FIXTURES r .f A.3 !��%''�,.✓'`�.)�.ry i
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE y
DESCRIBED RESIDENTIAL PROPERTY. ! POWER
��__�
SIGgATURE UTILITY CO.NOTIFIED
OF PERMITTEE FINAL
ALIDATION ARTHUR C:VEIT "
CK O CASH SUPERVISING ELECTRICAL ENGINEER
Ll02 9 0 1Z03 h0V26 2 D 5.00N
7SASS3OBS 5A 7-31 APPLICATION FOR PERMIT '
DtA TMENT OF BUILDING AND SAFETY -
COUNTY OF LOS ANGELES ELECTRIC
WILLIAM J. FOX, CHIEF ENGINEER
FOR APPLICANT TO FILL IN DISTRICTNO. GROUP I ZONE PERMIT NO.
ELECTRICIAN
RECEIVED BY READY FOR DATE ISSUED
ADDRESS . FIRST INSPECTION
CITY TEL.NO
COUNTY LICENSE NO. ® EXPIRES BUILDING ®�
PERMIT FEES ADDRE99
FEE
NUMBER EACH LOCALITY
LIGHT OUTLETS NEAREST
RECEPTACLES CROSS ST.
WALL SWITCHES OWNER
TOTAL OUTLETS 5c $ MAIL
ELEC. RANGES 85 ADDRESS
ELEC. HEATERS 25 CITY TEL. NO.
FIXTURES `� 1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS
MISC. APPLICATION AND STATE THAT THE ABOVE IB CORRECT
NUMBER OF LIGHT CIRCUITS d./ y AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES
NUMBER OF RECEPTACLE CIRCUITS AND STATE LAWS REGULATING ELECTRICAL WIRING.
MOTORS 1 CERTIFY THAT I POSSESS THE ABOVE VALID LOS
NUMBER HORSEPOWER FEE ANGELES COUNTY LICENSE. OR 1 AM THE LEGAL OWNER
NEW MVC. HP OVER INC. EACH OF THE RESIDENTIAL PROP DESCRIBED ABOVE.
%2 S LESS $ .25 SIGNATURE OF
%z 2 .SD PERMITTEE •
2 9 1.00 INSPECTION RECORD
5 15 1.50
15 5O 2.50
50 200 5.00
200 _500 10.00 J
5013 1000 15.00 Z
OVER 11300 20.00
M.O. BET/FREQ. CHANGER-HP Q'
WELDERS:AC-KVA O
GENERATORS - KW
TRANSFORMERS - KVA
TEMP. MOTORS (75% or CRIB.)
MOVED MOTORS (75% OF ORIGJ
misc.
SIGNS I
NO. NO.TRANS. APPROVALS
N0. NO.LAMPS
FOR EACH PERMIT: DATE INSP.ECTORP9 NAME
WIRING $1.00 CONDUIT f
FIXTURES $1.00 WIRINQt....i
SUPPLEMENTARY .50 FIXTURES C
POWER
TOTAL FEE $ UTILITY CO.NOTIFIED
/ FINAL
I ,
' WORKERS'COMPENSATION DECLARATION i 78-806 10/91 APPLICATION FOR [ELECTRICAL PERMIT
I.herebja affirm.tha't,I have a certificate.of.consent to self insure, CE-Bose f i /\ ��1
'(or a certir,;cafe of Workers' Compensation Insuran e, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy roof(Sec.``3800,Lab.C.)
PoIIC _� ;? ?�% - COmpan FOR APPLICANT TO FILL IN. JOB
❑ ertifted copy is hereby furnished. EACH NO. FEE ADDRESS
New Residential Bldgs.&Pools r
Certified copy is filed with. the co ilding inspection 1 & 2-Family,Sq.Ft.
$ _ $ LOCALITY �''
depart ent.
Multi-family Sq.Ft. NEAREST
CROSS ST.
Date Ap Residential Swimming Pools OWNER OR
a FIRM NAME
ICATE OF EXEMPTION F RK RS' MAIL
Outlets:Rec—Light—Sw._s 7—
s, '
COMPENSATION INSU CE ADDRESSe
(This section need not be compled i the work involved by the First 20
permit is.for one hundred dollars($100)or less.)
Total No. Additional CITY el.No
PLAN CHECK
I certify that in the performance of the work for which this permit -APPLICANT
is issued, I shall not employ any person in arty manner so as to
become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS
Total No. Additional CITY Tel.No.
Date Applicant Fixed Appliances Not Over 1 HP
NOTICE TO APPLICANT: If, after, making this Certificate of PERMIT
AwlExemption,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._ ADDRE
provisions or this permit shall be deemed revoked. Top FAU W.H.
CITY. Tel.No.
LICENSED CONTRACTORS DECLARATION Hood - Fan _ Other_
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. - Room Air Cond. UCEN O
(commencing with Section 7000)of Division,3 of the Business and REG.NUMBER Class.
Professions Code,and my license is in full force and effect. Power Apparatus&Large Appliances DISTRICT NO.
� P CESS BY
f Size&Type HP,KW,KVA,or KVAR ✓rOK
Licensee Number Lic.Class`-�ISL• Up to 1 Incl. FINAL
9�YY p Over 1 to 10 Inc DATE iu A DATION o
�t Date Over 10 to 50 Inc.. CJ'
FIN V
❑
lam mpt anis
c. Over
5000to 100 Inc. e 8 0 7.9 A pW„
B C.for thison
S rvices, -&Paneiboards # 0 0 0 0 0 2
- Z
Date: —o 0o Am oder 600 V 13250 LM
Signature 201 p.Under 600 V
❑
Exemption for Reg.Maint.Elect. Over 1000 Amp.or Ov 600 V . . 0 325 0 5
SINGLE FAMILY Temp.Powe yPO &Appurtenances P a O 7"8 7
HOME OWNER-BUILDER DECLARATIONSign with One ranch.Circuit
I hereby affirm that I am exempt from the Contractor's License Law
for the following reason(Section 7031:5,Business and Professions Additional Sign Branch Circuits
Code):
❑ I,as owner of the property,will do the work and the structure Misc.Conduits&.Conductors
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) _
and Professions Code). ;
• I
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(Sec.3097, PERMIT FEE (Sub-Total)
Civ.C.).
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE
Lender's Address n
I certify that I have read this application and state that the above TOTAL FEE
information Is correct:I agree to comply with all County ordinances
and State laws regulating Electrical wiring, and hereby authorize j
representatives of this County to enter upon the above-mentioned
property for' .. ectio urposes SEE REVERSE FOR EXPLANATORY LANGUAGE I
Signatu mi D to '