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76A663- E806 9-64 APPLICATION FOR ELECTRIC PERMIT
_63- .•E�1.r,
COUNTY OF LOS ANGELES `
DEPARTMENT OF COUNTY ENGINEER FAREII
ING
BUILDING AND SAFETY DIVISION S
JOHN A. LAMBIE, COUNTY ENGINEER
COLEMAN W. JENKINS, SUP'T. OF BUILDING LITY CI v
ESTFORAPPLICANT TO FILL IN S ST.RECEPT`•� TOTAL NO. EACH FE
LIGHT OUTLETS/ FIRST 20 S 20 $ OWNER rK t2 Ca _" Co .i
MAIL
ADD'L ADDRESS. �.� ST
SWITCH. OVER ZO .f0
LIGHTING- TOTAL t FIRST 20 .20 CITY TEL.NO. F'
FIXTURES _ ADO'L 1O ELECTRICIAN .
OV9R ZO
RANGES CLO.DRYERS WTR.HTRB. 1.00 ADDRESS
GARB.0I8P. STA.COOK CITY TEL.NO.
DISHWASH. AUTO.-WASH.1. STATE
SPACE HTRB. BTA.APP.C Va H.P.MAX.) .50 LICENSE NO.
MOTORSI OVER NOT OVER H.P. DISTRICT N ROS Z O
E P C
o t 1.00 e
I s 1.50. INSPE ION RECORD
s s 2.00 `
6 1 s 2.50
15 so 3.00 O0
50 100 5.00 O
W
SIGNSI NO.TRANS- - h
NO.LAMPS Z
SERVICE 0.600V-Nm OVER 200A 1.00
SERVICE 0.600V-OVER 200 A. 2.00 ,
SERVICE OVER 600V 5.00
MISC.
• I
PERMIT ISSUING FEE 2.00
SUPPLEMENTARY PERMIT ISSUING FEE 1.00 ,
r I-
TOTAL FEE
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION APPROVALS DATE INSPECTOR'S SIGNATURE
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CONDUIT
WITH ALL•COUNTY ORDINANCES'AND STATE 'LAWS REGULATING _ -
ELECTRICAL WIRING. WIRING .
I HEREBY.CERTIFY THAT I AM(PROPERLY REGISTERED AND%OR FIXTURES
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF
CALIFORNIA OR THAT I AM THE LEGAL OW R OF AND INTEND TO
RESIDE IN. T.HE•ABOVE CRIBE3 RESIDE L P RTY. POWER
SIGNATURE UTILITY CO.NOTIFIED i
OF PERMITTEE FINAL -
IDATION JOSEPH C. ROOHA• _
CK O CASH SUPERVISING ELECTRICAL ENGINEER
LACO1 4 9 9%'D' MAY 11 2 D 3.60^' cQIT
WORKER'S COMPENSATION DECLARATION 72D-00196AG63 DPW(12-91) APPLICATION FOR ELECTRICAL PERMIT LJ
76A683
I hereby affirm that I have a certificate of consent to,self Insure,
or a certificate of Worker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS BUILDING AND SAFETY DIV.
copy thereof(Sec.3800 Lab:C.) 1f
� t
Policy No. Company FOR APPLICANT TO FILL IN - JOB .. C`
❑ ADDRESS �J
Certified copy is hereby furnished. No"I(Residential Bldgs.&Pools NO. EACH FEE
1&2-Family,Sq.Ft. — $ $ LOCALITY «� ;.t �'� 9,17
❑ Certified copy is filed with the county building.inspection i — NEAREST
department; Multi-family Sq.Ft. CROSS Sr.
Dale Applicant Residential Swimming Pools AS ESSOR
MPP BOOK PAGE I PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER OR C
'COMPENSATION INSURANCE: Out ets:Rec._Light Sw. FIRM NAME l 0
First 20 MAIL
(Thls section need not be completed If the work Involved by the Total No. Additional ADDRESS
permit is for one hundred dollars($100)or less.)
1 certify that 1n the performance of the work for which this permit CITYTR, CCLel.No. C[' JIa3 If issued, I shall not employ any person in any manner so as to PLAN CFIE K
become subject to the Workers'Compe ation Laws. T Lighting Fixtures' First 20 APPLICANT
-� Total No. Additional.' � "
_ L ADDRESS �
1
Da(e .6- ' '- Appllcarit RESIDENTIAL APPLIANCES NOT OVER 3 HP.
NOTICE TO s erfificate of CAPPLICANT: If, after making th IN Tel.No.
Exemption,,you should become subject to the Workers'Compensation OTHER APPLIANCES NOT OVER 3 HP.
PERMIT
provisions of the Labor Code,you must forthwith comply with such
Power Apparatus&Large AppliancesAP
provisions or this permit shall be deemed revoked. PLICANT T
LICEN.SED.CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS OfT e r5fi�,
I hereby affirm that.I am licensed under provisions of Chapter 9
(commencing with Section 7000 of Division 3-of the Business and f Over 3t 10 Incl. CITY Tel.NCY
( g ) �4 �7 9Z-Zj{
Professions Code,and my license is In full force and effect. Over 10 to 50 Incl.
2.
LICENSE OR Claes.
�•
r� ( Over 50 to 100 Incl. REG.NUMBER yt7•-Z�SO 1.
License Number
3qa''u� Lic.Class Over 100 DISTRICT NO. SEED BY O
y V
' r Services, bd. MCC anelboar � �
Contractor 4 6�F IPfi'y�f C01tt� Date. (--7- t! In er 00 pNA 0
❑ ° 400-1000 Amp.Under 600 V 4
I am exempt under Sec. .VALIDATION
Over 1000 Amp.or Over S00•V, FINAL r 11
III
B.&P.C.for this reason BRANCH CIRCUIT FEES BY
Date: 6A,or 20A,120V..Lighting or Recept. Z_
Signature 1 1 To 10 Branch Circuits
11 To 40 Branch Circuits
41 Or More Branch Circuits ,
❑ Exemption for Reg.Maint.Elect. 154,20A,208V To 277V Lighting Br.Circuits
SINGLE FAMILY Teri p.Power Pole&Appurtenances t;f'`"s'
HOME OWNER-BUILDER DECLARATION f Act-,-,
�
Sign with One Branch Circuit ., , 7 c
I hereby affirm that I am exempt from the Contractor's License Law I �,'�'I %63=sl.5
for the following reason(Section 7031.5, Business and Professions Addltlonal Sign Branch Circuits
Code): i
I T'"�tC
T C.lS
❑ I,as owner of the property,will do the work and the structure MI c.Conduits&Conductors T OTA L 63 .45
is not intended or offered for sale(Section:7044, Business Other(See Complete Fee Schedule)
and Professions Code).. CHECK 143=455
CONSTRUCTION LENDING AGENCY I ru
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.) 1f
PLAN CHECKING FEE I IJ{]) _I,0 3,
Lender's Name ? 566 1 rim 01:f•_
PERMIT ISSUING.PEE 1.4 ►
Lender's Address f
I certify that I have read this application and under penalty of purjury state TOTAL FEE
r ,
that the above information is correct. I agree to comply with all County ,I
ordinances and State laws regulating Electrical wiring,and hereby authorize
representatives of this County to enter upon the above-mentioned property ;
for inspection purposes. I SEE REVERSE FOR.EXPLANATORYSiGLANGUAGE ,
`�-
NATURE OF'P EE -^ DATE ' f
I
78p883-CE808 8-84 APPLICATION FOR UeCTRICAL ERMIT
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER [EAREST
UILDING
BUILDING AND SAFETY DIVISION DDRESS A
JOHN A. LAMBIE, COUNTY ENGINEER
WILLIAM A.JENSEN,SUPT OF BUILDING OCALITY eM
FOR APPLICANTTO FILL IN ROSS ST. 1,38 Tmas
REC T. TOTAL. NO. EACH FEE '
LIGHT OUTLETS FIRST 20 20 $.20 ffi 00 OWNER' i
MAIL
K�Q ADD�L ADDRESS �� E., SBCOIId Str•
SWITCH. 130 539 _ OVER 20ag_ .10 51
LIGHTING TOTAL ��ADD'L
T 20 .20 0 CITY Darn TEL.NO. UITB 3-15
FIXTURES 124 .to ELECTRICIAN 1 20
RANGES 2 CLO.DRYERS WTR.HTRS. 1.00 2 00 ADDRESS'
GARB.oISP.10 BTA.COOK CITY TEL.NO. f•
DISHWASH. 15 AUTO.-WAa�SH�.p}� ��ryry 73 36 50 STATE $ 190 C-10
SPACE HTRB. STA./QPM.( H.P�1(4X.) 36 .50 31 IQ& LICENSE NO.
MOTORS, OVER NOT OVER H.P. DISTRICT N GROUP ZO P C S D
A Units1 lg 1.00 18 00IT O:p
1 3 1.50 INSPECTION RECORD >
It
3 8 2.00 V
8 .15 2.50 ad
18 50 14.00 V
SO 100 5.00 pW-.
H
SIGNS, NO.TRANS. Z
NO.LAMPS
SERVICE 0-SOOV-NOT OVER 200A 1.00 4 DQ
SERVICE O-SOOV-OVER 200 A. 2.00
SERVICE OVER SOOV 5.00
MISC.
PERMIT ISSUING FEE 2.00 2100
SUPPLEMENTARY PERMIT ISSUING FEE 1.00
TOTAL FEEIsla
1HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION APPROVALS DATE INSPECTOR'S SIGNATURE
AND STATE THAT THE ABOVE IB CORRECT AND AGREE TO COMPLY CONDUIT A
WITH ALL-COUNTY THE.
'AND STATE LAWS REGULATING
ELECTRICAL WIRING. WIRING
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERR,6 AND/OR Jr
LICENSED AS REQUIRED BY LOS ANGELES COUNTY ANIS STATE OF FIXTURES
CALIFORNIA OR THAT 1 AM THE LEGAL. OWNER OF THE ABOVE
DESCRIBED RESIDEHTIA PR P Y.. POWER
SIGNATURE AK
UTILITY CO.NOTIFIED
OF PERMITTE v erg
FINAL
IDATION ARTHUR C. VEIT
�� CK MO CASH SUPERVISING ELECTRICAL ENGINEER
(.5'40/
LAGO 4 5 2 6'2 AUG 11 2 D 13 2.80-
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