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DS-SA APPLICATION FOR ELECTRIC. ERtl II 1
BB.6A DMSION OF BUILDING AND SAFETY �UpG
Department of County Engineer
County of Los Angeles BUILDING
WM.J.FOX.COUNTY ENGINEER ADDRESS[S lV �/C/& jrO,S
CASSATT D.GRIFFIN.SUPT OF BUILDING
LOCALITY
FOR APPLICANT TO FILL IN NEAREST
PERMIT FEES CROSS ST. f77
NUMBER EACH FEE
LIGHT OUTLETS OWNER
RECEPTACLES MAIL
ADDRESS
WALL SWITCHES
TOTAL OUTLETS 5¢ $ CITY TEL.NO.
ELEC.RANGES �1 25 ELECTRICIAN
ELEC. HEATERS y 25 ADDRESS .y
KW EA CITY y° TEL.NO. XSW
FIXTURES 5 LICENSE NO. ..7.y/
NUMBER OF LIGHT CIRCUITS - DISTRICT NO. GROUP ZONE READY FOR INSPECTION
NUMBER OF RECEPTACLE CIRCUITS r
MOTORS -
I Nov.
NUMBER HORSEPOWER FEE + INSPECTION RECORD
NEW MVD. HP OVER INC. EACH
ut
lh 2 .50
2 5 1.00
5 15
15 50 2.50 8 Be)yr A09-t-:fi
50 - 200 5.00
MISC.
9- 7-6-16fk 6VP ,f7-KP P
7✓1�-HTr_-W p - Bur HfiD 7Q
NO.SIGNS NO.TRANS. L — t/'TILE ASF_TT/!"A,? TO
NO.SIGNS NO.LAMPS APc
FOR EACH PERMIT: Aloff p�
WIRING
FIXTURES $1.00 eff vd/°�h
,9 ro 6 J
SUPPLEMENTARY .50 APPROVALS Ir y„j' qgfj/fj,p a-
TOTAL FEE S I d 9 DATE INSPECTORS SIGNATURE
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS"APPLICATION CONDUIT /0 3®� t
AND: STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY Fes• , r�J�l
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING WIRING -� /{LAY
ELECTRICAL WIRING. -
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR FIXTURES
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF '
CALIFORNIA OR THAT I' AM TH- LEGAL OWNER OF THE ABOVE POWER
DESCRIBED RESIDENTIAL P P �1
SIGNATURE & UTILITY CO.NOTIFIED -a� a(7 Ra tf�fiEf
OFPERMITTEE +.•i r'i t•l e 1-61/I•re__vti__d FINAL kQto 44dpft&
WILLIAM J.FOX.Co rY INEER- VALIDATION A.C.VEIT.CHIEF ELECT.INSPECTOR
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