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76A669-CES.06 6-62 APPLICATION FOR ELECTRICAL PERMIT
COUNTY.OF LOS-ANGELES
DEPARTMENT OF COUNTY ENGINEER BUILDING
BUILDING AND SAFETY DIVISION ADDRESS O S /-I V
JOHN A. LAMBIE, COUNTY ENGINEER
WILLIAM A.JENSEN,SUPT OF BUILDING LOCALITY .. / lr �%
NEAREST
FOR APPLICANT TO FILL IN CROSS ST. Zr OZ
RECEPT. TOTAL NO. EACH FEE
OUTLETS FIRST 20. $.20 $ OWNER. ,
LIGHT MAIL
SWITCH. OVEADIR
2 10 ADD(ZE86
OVER 2O
TOTAL CITY TEL.NO.
LIGHTING 1 FIRST 20 .20
FIXTURES 1 ADDPL .1O ELECTRICIAN "� OOL �
OV R 20
RANGES CLO.DRYERS WTI.HTRS. 1.00 ADDRESS
GARB.DISP.. STA.COOK �f
DCITY B+f l7&rEL.NO.
ISHWASH. AUTO.-WASH.
STATE
SPACE HTRS. BTA.APP.(Vs H.P.MAX.) .50. LICENSE NO. d
MOTORS. OVER NOT OVER H.P. DISTRICT O. G UP Z NE P CESSED Y
O 1 1.00 (' r
1 s 1.so INSPECTION RECORD
s 9 2.00
s is 2.50 I
1s, so 3.00
.d a
so 100 ' 5.00
SIGNSS NO.TRANS.
OL
NO.LAMPS
SERVICE O-SOOV-NOT OVER 200A 1.00 V
t•
Lu
SERVICE O-600V-OVER 200 A. 2.00 y
SERVICE OVER 600V 5.00 ?
MISC.
PERMIT ISSUING FEE 2.00 0
SUPPLEMENTARY PERMIT ISSUING FEE 1.00
'DOTAL FEE $
i
1 HEREBY. ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION APPROVALS s DATE INSPECTOR'S SIG ATURE
AND STATE THAT THE ABOVE 18 CORRECT AND AGREE TO COMPLY CONDUIT ! ~ +
WITH ALL-COUNTY ORDINANCES.AND STATE LAWS REGULATING / (K %"�3 "•' •r
ELECTRICAL WIRING. WIRING !i;'
• 1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR r�
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF FIXTURES
CALIFORNIA OR THAT 1 AM HE EGA O F THE ABOVE i
DESCRIBED RESIDENTIAL POWER
SIGNATURE UTILITY CO.NOTIFIED yy.`�A-'
OF PERMITTEE FINAL /.+i I�q� 3 1
LIDATION ARTHUR C. VEIT °
J cK/ MO CASH SUPERVISING ELECTRICAL ENGINEER
r
8 0I
78s-SA 5
osAPPLICATION FOR.EI,LECTRIC PERMIT
1
s5 DIVISION OF BUILDING AND SAFETY
Depa hent of CountyLEngineerCc inty of Los A �u1LDING� [`OJ� 0WM.J.FOXCOUNTYERDDRESS J Popm CASSATT D.GRIFFIN.SUPDING Il
mm LOCALITY . �l
FOR APPLICANT TO FILL IN NEAREST /"—/�
PERMIT FEES . cRoss sT. i r/!1
NUMBER EACH FEE
LIGHT OUTLETS OWNERMAIL
RECEPTACLES ADDRESSS3sb S f MAI Q 1K
WALL SWITCHES
TOTAL OUTLETS 5 S LITY TEL.NO.
ELEC.RANGES 25 ELECTRICIAN 6 L 6
'1 ELEC. HEATERS 25 ADDRESS /16 Zji S7
g. KW EA CITY TEL.NO
FIXTURES 5 LICENSE NO.
NUMBER OF LIGHT CIRCUITS' - DISTWr-T NO. I GRJUP I ONE I READY FOR INSPECTION
NUMBER OF RECEPTACLECIRCUITS `I
MOTORS
s NUMBER HORSEPOWER FEE ENSPECTIO RECORD
fiF NEW MVD. HP OVER INC.' EACH
f
.y2&LESS $ .25
s:
2 50
2 5 1.00
' 5 15 1.50 $
k 15 50 2.50
50 200. 5.00
s I '
' MISC.
n
NO.SIGNS NO.TRANS.
NO.SIGNS NO.LAMPS
FOR EACH PERMIT:
WIRING $1.00 O O
FIXTURES $1.00 �.
SUPPLEMENTARY 50 APPROVALS
TOTAL FEE $ / iJ DATE' INSPECTOR'S SIGNATURE
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CONDUIT
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY /,
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING WIRING
r ELECTRICAL WIRING.
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR FIXTURES
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF
CALIFORNIA OR THAT 1 AM THE LEGA NER OF THE ABOVE POWER
DESCRIBED REBID T .
SIGNATURE UTILITY CO.NOTIFIED
OF PERMITTEE 1 FINAL, +�j� Gvvv�. S•iz
WILLIAM J.FOX.COUNTY ENGINEER VALIDATION A.C.VEIT.CHIEF ELECT.INSPECTOR''
k(;a 8 8 2 Y UR AUG r :L .;:e 5 �'
WORKERS'COMPENSATION DECLARATION " 76q�3 50/et•-" �- APPLICATION FOR ELECTRICAL PERMIT
I herLby affirm that I have a certificate of consent to self C�llclbG
insure, or a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES BUILDING.AND SAFETY
or a certified copy thereof (Sec. 3800, tab. C.)
Policy No.—Company FOR APPLICANT TO FILL IN JOB �`f� ,s
❑ Certified.copy is hereby furnished. ;New Residential Bldgs. &Pools EACH NO. FEE ADDRESS J L� +�'
❑ 1 8 2-Tamil LOCALITY
Certified.copy is filed with the county building inspec- y;Sq. Ft.
$ — $ /�
tion department. Multi-family Sq. Ft. — 'NEAREST
Residential Swimming Pools. OWNER T.
15 A,'Alc
Date Applicant
FIRM NAME LOR L
CERTIFICATE-OF EXEMPTION FROM WORKERS' Outlets: RecLi �Sw CW MAIL
COMPENSATION INSURANCE ght First 20 ADDRESS
(This section need not be completed if the work involved by Total No. if
Z Additional CITY Tel. No.
the permit is'for one hundred dollars($100)or less.)
PLAN CHECK
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'Compensation Laws. Lighting Fixtures First'20 ADDRESS
Total No. 2U. Additional CITY Tel. No.
Date " licant%if&)+ JOZ&r
PP Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, after making this Certificate of ° APPLICANT ,� �rC�r
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 a
with comply with such provisions or this permit shall be Top — FAU W.H. —
deemed revoked. Hood Fan r Other_ C1,111 . a Tel. IVo
� _
LICENSED CONTRACTORS DECLARATION LICENSE O
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. .4. Room Air Cond. — REG.NUMBER Class ,.
(commencing with Section 7000) of Division 3 of the Business Power Apparatus&Large Appliances DISTRICT NO. PROCESSED BY
and-Professions Code,and my license is in-full force and effect. IL
I Size&Type HP, KW, KVA, or KVAR' r
License Number 7 �� Lic, Class �� I p-M ^� FINAL
Up to 1 Incl.
s ✓
y��s I -VA 1 to 10 Incl, DATE VALIDATION 1—
09
Contracfor • • a d=m Date vr- . Over 10 to 50 Incl. FIN 0
❑ I am exempt under Sec. Over 504o 100 Inc. BY tag
IL
Over 100 t
B.BP.C. for this reason
f H
Services, Swbd., MCC&Ponelboards
Date: 0 -200 Amp. Under 600 V
Signature 201 - 1000 Amp. Under 600 V
❑ I -
Exemption for Reg. Maint. Elect. Over 1000 Amp. or Over 600'V
�I
SINGLE FAMILY ' Temp: Power Pole•&Appurtenances
HOME OWNER-BUILDER DECLARATION I Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License + Additional Sign Branch Circuits
Law for the following reason (Section 7031.5, Business and j
Professions Code): ;0 7 0 8 7 8
❑ 1, as owner of the property, .will do the work and the Misc. Conduits 8 Conductors
structure is not intended or offered for sale (Section Other(See Complete Fee Schedule)_ ® t o e 0 0 0.2
7044, Business and'Professions Code).
CONSTRUCTION LENDING AGENCY' 2- 10250
I hereby affirm that there is a construction lending agency for I o o 1 0 Z5 0 6
the performance of the work for which this permit is issued PERMIT FEE (Sub-Total)
(Sec. 309.7, Civ. C.). I G25-82
I PLAN CHECKING FEE
Lender's Name PERMIT ISSUING FEE
Lender's Address
I certify that I have read this application and state that the I..TOTAL FEE
above information is.correct. I agree to comply with all County
ordinances and State laws regulating Electrical wiring, and
hewlff�
this County to enter upon
thenspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
'"Z20 0 02
ature of Permittee Date