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DOSAPPLICATION FOR E-LECTRIC PERMIT 1 -
DOS-BA
DIVISION OF BUM= AND SAFETY
Department Of County Engineer BUILDINGIt
County of LOB Angeles ADDRESS .0 �7 —A+ It,M.
JOHN A.LAMBIR.COUNTY ENGINEER
CASSATT D.GRIFFIN.SUPT OF BUILDING •C.ALI /
FOR APPLICANT TO FILL IN NEARI
PERMIT FSEs C OSS ST.
NUMBER OWNER .�il�
LIGHT OUTLETS MAIL
RECEPTACLES ADDRESSL4
WALL SWITCHES CITY' v .►1 Y\TEL.
!4N_O`N
7O/
TOTAL OUTLETS ® 5¢ $ '
ELECTRICIAN
ELEC.RANGES 25 ADDRESS
ELEC.HEATERS 28
CITY TEL.NO.
KW�
STATE
FIXTURES 5 LICENSE NO.
MOTORS DISTRICTrNO. GROU ZA READY FOR INSPECTION
NUMBER HORSEPOWER FEE J�
NEW MVD. HP OVER INC. EACH
rk L68B $ .25 ngs=TION RECORD
Yz 2 .50 /Qo/Y6;,r d7 1,VJHG A191
2 5 1.00
5 Is 1.50 0 fj F�O G��E F STIP �.�`�'i✓�%�v'+�
IS SO 2.50
SO 200 5.00
MIS 4 -
NO.SIGNS NO.TRANS.
NO.SIGNS NO.LAMPS
FOR EACH PERMIT:
WIRING $1.00 : 100
FIXTURES $1.00 4�
SUPPLEMENTARY .50
APPROVALs.
TOTAL FEE $ DATE INSPECTOR'S SIGNATURE
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CONDUIT
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING WIRING -/ELECTRICAL WIRING.
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR FIXTURES = f
LICENSED AS REQUIRED 11Y LOS ANGELES COUNTY AND STATE OF
CALIFORNIA OR T T_1 LEGAL OWNER OF THE ABOVE POWER
DESCRIBED RESIDE 2!7
SIGNATURE UTILITY CO.NOTIFIED
OF P€RMI FINAL'
JOHN A.LAMBIE:COUNTY ENGINEER VALIDATION ARTHUR C.VEIT.CHIEF ELECT.INSPECTOR
CK NO CASH
',AC,0 4 1 5 7 N DIAR 15 2 •2.3 5 In
Imo` AI
WORKERS'C.OMPENSATIONDECLARATION ICE-866G (2-80) APPLICATION FOR ELECTRICAL PERMIT
1 hereby affirm that I have a certificate of consent to'self COUNTY OF LOS ANGELES ^—7BUILDING AND SAFETY
insure,or a certificate of Workers'Compensation Insurance,or / '
a certified copy thereof(Sec:3800,Lab.C.)
FOR APPLICANT TO FILL IN JOB �/ ./ v
Policy No. Company ADDRESS�7 7 �� / e/
New Residential Bldgs.&Pools EACH NO. FEE
F1 Certified copy is hereby furnished. 1 &2-Family,Sq. Ft. $ — $ LOCALITY
❑ Multi-family Sq. Ft. — NEAREST
Certified copy is filed with the county building inspection • CROSS ST
department. Residential Swimming Pools OWNER OR
FIRM NAME 0/1' Sf/<
Date Applicant Outlets: Rec._LightSw. MAIL
First 20 ADDRESS �°� / /�� � r�
CERTIFICATE OF EXEMPTION.FROM WORKERS' Total No. Additional CITY3J`�7�i(asaL
COMPENSATION INSURANCE Tei No.
PLAN CHECK }
(This section need not be completed if the work involved. APPLICANT 0
by the permit is for one hundred dollars ($100) or less.) Lighting Fixtures First 20 ADDRESS V
Total No. Additional
I certify that in the performance of the work for which thisCITY Tel No. O
Fixed Appliances Not Over 1 HP
permit is issued, I shall not employ any person in any manner PERMIT 0
sq as to become subjdct to the Workers'Compensation Laws. Range_Heater D.W. _ APPLICANT W
Oven _ Dryer_W.M._ ADDRESS N
fi
Date/— �`
/qkpplicantTop _FAU _W.H.._/t.�- - CITY Tel No. Z
Hood — Fan —Other—.
NOTICE TO APPLICANT: If, after making this Certificate of Disp. _Room Air Cond. LICENSE OR
Exemption, you should become subject to the Workers' ! REG.NUMBER Class
Compensation provisions of the Labor Code, you must forth- Power Apparatus& Large Appliances DISTRICT NO. PROCES ED BY
Lyith comply with such provisions or this permit shall be
deemed revoked. Size&Type HP,KW,KVA,or KVAR
Up to 1 Incl.
• FINAL
�e
LICENSED CONTRACTORS DECLARATION Over 1 to 10 Incl. DATE Over 10 to 50 Incl. VALIDATION
I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. FINAL
? (commencing with Section 7000)of Division 3 of the'Susi- Over 100 BY
ness and Professions Code,and my license is in full force and
affect. Services r
License Number Lit.Class 0-200 Amp.Under 600 V
201-1000 Amp.Under 600 V
"ontractor Date Over 1000 Amp.or Over 600 V
HOME OWNER'-BUILDER DECLARATION Temp.Power Pole&Appurtenances
hereby affirm that I am exempt from the Contractor's Sign with One Branch Circuit
.icense Law for the following reason (Section 7031:5, Busi- 1Additional Sign Branch Circuits J 7 9. 1
less and Professions Code):
Misc.Conduits&Conductors i•I o 0 0 0 '0 7
I, as owner of the property, will do the work and the Other(See Complete Fee Schedule)—
structure is not intended or offered for sale (Section 2 o o 1 9 0
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY o 0 0 1 •� 0
hereby affirm that there is a construction lending agency
or the performance of the work for which this permit is
ssued(Sec.3097,Civ.C.). PERMIT FEE (Sub-Total) 00 1. 1 9-81
,ender's Name ;PLAN CHECKING FEE (One-Fourth Permit Fee)
.ender's Address I PERMIT ISSUING FEE
certify that I have read this application and state that theTOTAL FEE g
Bove information is correct.1 agree to comply with all County
rdinances and State laws regulating Electrical wiring, and
ereby authorize representatives of this County to enter upon
e above-mentioned property for'inspection purposes-. SEE`REVERSE FOR EXPLANATORY LANGUAGE
414'. 1 _ --F-4 ,
Signature of Permittee pate