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APPLICATION FOR ELECTRICAL PERMIT 1
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER BUILDING INO.BUILDING AND SAFETY DIVISION ADDRESS D7. 1.!OLIN A.LAMBIE.COUNTY ENGINEER
WILLIAM A.JENSEN.SUP'TOF BUILDING LOCALITY
FOR APPLICANT TO FILL IN NEAREST
PERMIT FEES cRoss srOWNERITEM NUMBER EACH FEE MAIL
OUTLETS: S S ADDRESS
LIGHTS RECEPT. SW. .10 -
ING FIXTURES .10CITY TECLO.DRYERS ELECTRIC! N
WATER HEATERS .80 ADDRESSELEC.SPACE HTRS. DISHWASHERS —CITY GARBAGE DISPOSERS AUTO.. STATEWASHERS BTA.COOKING UNiT3 .28LICENSENO. 1/
MOTORS: OVER INC. H.P. DISTRICT,Q. GROUP ONE PROCESSED BY
0 — Ya .25
DISTRICT,
v/a — 2 .00 ` ,v INSPECTION RECORD
2 — 8 t.OG +..>• L��!+ f !!tom AA �I 7 11Ai Dom.
8 !9 1.80 45-` 0
is — 50 2.90
SO— 200 8.00
V
SIGNS: NO TRANS. H
NO.LAMPS
Z
SERVICE 0.600V t.00
SERVICE OVER 600V r 9.00
MISC.
Y`
WIRING PERMIT too
FIXTURE PERMIT 1.00
SUPPLEMENTARY PERMIT .80
e
TOTAL FEE S
1 HfiREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION APPROVALS DATE INSPE R'881GNATURE
AND STATE THAT.THE ABOVE IS CORRECT AND AGREE TO COMPLY CONDUIT
WITH ALL COUNTY ORDINANCES AND STATS LAWS REGULATING _
ELECTRICAL WIRING.
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR WIRING 'G,v ,
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF FIXTURES
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF TH OVB
DESCRIBED RESIDENTIAL OPERTY,
POWER
SIGNATURE UTILITY CO.NOTIFIED
OF PERMITTE
F1NA n ed
VALIDAT9" ARTHUR C.VEIT.
CK NO tC."HSUPERVISING ELECTRICAL ENGINEER
L ' 0599 01-40 JUL26 2 0 2:5D
WORKER S'COMPENSATION DECLARATION C A663 EA06G (2-80) APPLICATION FOR ELECTRICAL PERMIT ,
I hereby affirm that I have a certificaile of consent % self COUNTY'OF LOS ANGELES BUILDING AND SAFETY
insure,or a certificate of Workers'Compensation Insurance,or
a certified copy the of(Sec.3800,Lab.C.)
?��sFOR APPLICANT TO FILL IN SOB ;
Policy No. Companys � `^�L
• New Residential Bldgs.&Pools EACH NO. FEE ADDRESS E
Certified copy is hereby furnished. 1 &2-Family,Sq. Ft. $ — $ LOCALITY
Multi-family Sq. Ft. NEAREST �•
��de
fied copy is filed with the c unty building inspection. CROSS ST
art ant. Residential Swimming Pools
P I' OWNER OR
"` 1'r FIRM NAME
Date
�pplicant Outlets: Rec.—Light Sw•. MAI L
First 20 ADDR C.
CERTIFICATE OF EXE ION FROM WORKERS' Total No. Additional '
COMPENSATIO INSURANCE CI �� „ Tel No. –�, N.
}
PLAN CHE Cli
O.
(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 040a
I certify that in the performance of the work for which this Fixed Appliances Not. 1 HP CITY Tel No. O
permit is issued; I shall not employ any person in any manner
PERMITV
so as to become subject to the Workers'Compensation Laws. Range—Heater D.W. _ APPLICA �� W
Oven _ Dryer_W.M._ ADDRESS
Date Applicant Top ,_ FAU _W.H.,_ Ilk Z
Hood _ Fan _Other_
'CIT arm lA� Tel No.
NOTICE TO APPLICANT: If, after making this Certificate.of . Disp. _Room Air Cond— +l LICENSE OR v�
Exemption, you should become subject td the Workers' REG,NUMBERS Class
Compensation provisions of the Labor.Code, you must forth- Power Apparatus&Large Appliances i DISTRICT NO. PROC SSED BY
with comply with such provisions or this permit shall be•'
deemed revoked. Size&Type HP,KW,KVA,or KVAR D a v l
Up to 1 Incl. b 0
Over 1 to 10 Incl. FINAL
DATE
LICENSED CONTRACTORS DECLARATION• VALIDATION
� Over 10 to 50 Incl.
I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. FINAL
9 (commencing with Section 7000)of Division 3 of the Busi- Over 100 BY
ness and Professions.Code, and my license is in full force and ,I
effect. r Services
License.Numbe'`�-Z2-60 Lic.Class/" �3 1 0-200 Amp.Under 600 V /✓� �
201-1000 Amp.Under 600 V
Contractor. � Date ^;���� • Over 1000 Amp.or Over 600 V
HOME OWNER-BUILDER DECLARATION Temp.Power Pole&•Appurtenances
I hereby affirm that I am exempt from the.Contractor's i Sign with One Branch Circuit
License Law for the following reason (Section 7031.5, Busi- Additional Sign Branch Circuits a
ness and Professions Code): 5Misc.Conduits&Conductors
❑ 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 0 0 0 0 0
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY o o k y('
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is PERMIT FEE (Sub-Total) "• ° ° 6,5 0 L
issued(Sec.3097.,Civ.C.).
Lender's Name
PLAN CHECKING FEE (One-Fourth Permit Fee) (+'� ��'7 p�•
Lender's Address PERMIT ISSUING FEE
I certify that I have read this application and state that the TOTAL FEE A
above information is correct:I agree to comply with all County
ordinances and State laws regulating Electrical wiring, and
hereby auth rize representatives of this County to enter upon
the bove-m tioned arty for inspection purposes.
_ SEE'REVERSE FOR EXPLANATORY LANGUAGE
ig ature of Permittee ., ate.j
� KERS'COMPENSARON DECLARATION 7941868 10/81
'I'that I have a cettihode d consent to one fierce. CE-°°°° APPLICATION FOR ELECTRICAL PERMIT
ora of Vlbrkes'Comparoatbn Insurance,or a r 11110 COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof(Seo.58001ab.C.)
Policy No. , + Cay FOR APPLICAM TO FILL IN JOB
❑ CerMW copy In hereby fumlehed. New RLwidential Bklga.a Poole EACH NO. FEE A Q`4 Ve .
1 8 2-Family.Sq.Ft. s — i QTY n G
❑ capered copy le filed with the county building inspectionMulCaamfy 84 Ft NEAREST—
mot"e"t' CROW sr US&IN t
Date Applicant Resklentatl Swimming Pools
CERRFICATE OF EXEMPTION FROM WORKERS' FIVA�� S
COMPENSATION INSURANCE Outlo 5— First 20�
ppb saction need not be conrI , K the work Involved by the ToW No Additional CITY V G Til.Na
perm@ le for one hundred dollars(=100)or lose.)
I certify that In the psr}ormance of the work for this permit PIAN CHECK
APPLIGAArr
to leered. I shall not employ, any pe man so an to
become suk%d to the Vftlaene' Lighting Fbdurea Flret 20 ADDRESS
Dateq[j Apel Told No.J0__. Additional CITY Til.No.
NOTICE ti, atter making bole Certificate Fred Appliances Not Over 1 HP pERpR p�j
Eremplbn,you should became oulO t to 4e Vil rlon'Compere n Reece_ Heater DW. _ APPLti,ANr •'` G
poNNons d the Labor Cads.you must forthaft comply actin Ohren _ Dryer_ W.M._ ADDRESS ? v�
provlders or thin permit shall be deemed revoked. Top _ FAU _ W.H. _
LICENSED CONTRACTORS DECLARATION Flood _ Pee Off_ Cuv pte eayeTil.No.2X—
I hereby offFm that I am licensed under provisions of Chapter 9 ObIL — Room Air Cond. UCENGE OR Ctea
(comrnenchop Wien Section 7000)ofDlvbbn 5 of the Business and REGI.NUMBER
Probodo a Code,and na license Is in full force and effect Planar Apparatus A Lafg•App11onow DISi1�CP110 0
Slee a lWw HP.KW,KV►,or K%AR J $
License Number Lb.Class Slee
to 1 Ind. FI
Date
C_
CorhtraCtor Ohtix 1 to 10 Incl. n L d
Over 10 to 80 Ind.
NALZ 4'
❑ 1 am Pmpt under Seo. Over 50 to 100 Inc. BY .{
SAPJC.far this reason Over 100 r lY>t
Dets Services,Swbd.MCC a Parolbowde Z
0-200 Amp.Under Soo V
Signature 201- 1000 Amp.Under 800 V
Over 1000 Amp or Over 800 V
❑ Exemption for Reg.Maert Elect.
SINGLE FAMILY_ TSign
emp Power Pule a Appurtenances
I hereby offl�that I am 1 1 t from the Contractor's License Len with One Branch Circuit
for the following reason(Section 7051.5,Business and Profesdm Additional Sign Branch Circuits
Cods):
❑ I,ee owner of the property,will do the work and the structure Mac.Conduits a Conductors
Is not In-anded or offered tar sob(Section 7044,Business Other(See Complete Fes Schedule) _ ►
and Protesdone Code).
CONSTRUCTION LENDING AGENCY
I hesby affirm that there in a comb uctlon lending agency for the
performance d the work for which thin permit In issued(sac.5097, PERMIT FEE (Sub-Tatel)
Civ.c.).
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE
Lehder+'a Address
I certify that I have reed this applkatlorh and stats that the above TOTAL FEE
Information le correct I agree to comply with all County ordinances
and a j an mmm Electrical wkkg, and horeby outhortas
reps this to ender upon the abovo-ma boned
SEE REVERSE FOR EXPLANATORY LAMLL40E
Slgrhatrre of Permittee