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76ASGS CESDO ID.0 APPLICATION FOR ELECTRI PERMIT
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER BUILDI No gO
BUILDING AND SAFETY DIVISION ADDRESS (a b
JOHN A LAMBIE. COUNTY ENGINEER
WILLIAM A JENSEN,SUP T OF BUILDING LOCALITY
NEAREST
APPLICANT TO FIL IN I CRD65 5'T
Iacm TOTAL NO uCN SEE e
OUTLETS [7iR
IT 20 ^I t 2O t OWNER . J /Ju6HT / MAIL
SWITeH ADO 1 ADDRESS
/ _ OVER LLO 10 �5 )
TOTAL CITY TEL NO
LIGHTING FIRer 20 � YO q _
FIXTURES / ADD L J 5� �.`
oven 20 10 ELECTRICIAN
RANG" CLO DRYOlE WTN HTRI too
DIRP STA COOK CITY,
DIRHWASH AUTO W CITY. '�� TEL N GJ
STATE
VACS NT" STA APP HP MAR ) SD LICENSE NO
MOTORS, DYER Nor oval NP DIST Np'y� GROyU—P Z NE PR q BY
O 1 100 � (j 1—
I — a 1150 1 INSP CTION RECORD
a S 200 f 6
S IS 250
15 50 a 00
�I
DO 100 500 -
NO TIIAMS
SIGNS NO LAI / 1 /
.CaJ i
SERVICE e00Y NOT w"200A 100
OV
SERVICE O 600V Ova 200 A 200
SERVICE OVER SOOV 500
MISE
PERMIT ISSUING FEE 200
SUPPLEMENTARY PERMIT ISSUING FEZ too
TOTAL FEE t
I NR "MRI SY ACKNOWLKOG[ THAT 1 HAVE R THIS APPLICATION DAT[ INQ[CTOR S S u
AHD STAT[ THAT THE AOVK It CDRCT AND AGREE TO COMPLY CONDUIT
WITH ALL COUNTY ORDINANCES AND STATS LAWS REGULATING
ELECTIIICAL WIRING WIRING A
1 H"6iY CKWIVY THAT 1 AM PROP[RLY OISTCRm ANp/OR
LICENSED " REGU BY LOS ANOCW CO AND RAT[ OP FIXTURES IG L A
CALIFORNIA OR TNA- AM THE LEGAL O OP THE ABOK
D"CI11RD R"IDEIT / POWER
OP NATUR f6 / UTILITYCO NOTIFIED
FINAL
�LI ARTH R C VETT /
CK MOO CASH
SH BUrZRVItING ELECTRICAL ENGINEER
[AC0 6 4 9 5:o MR 11 2D 14.90- v
70AES9 CEEOE 10.62 APPLICATION FOR ELECTRICAL PERMIT
COUNTY OF LOS ANGELES / TQ
DEPARTMENT
BUILD NG AND SAFETY DIV]SIONER ADDR6HB
JOHN A LAMBIE, COUNTY ENGINEER
WILLIAM A JENSEN, SUP T of BUILDING LOCALITY
NEAREST
OR APPUCANTOFILL IN CROSS ST
R[CSPr 7l TOTAL No EACH FEE
OUTLETS FIRST 20 120 S aw OWNER
LIQ.T 4 MAIL
ADD
SWITCH 7� oWR LO 10 ADDRESS
GHTING
LTOTAL FIRST 20 20 CITY TEL No
I
FIXTURES ADD L
D L 10 ELECTRICIAN
ADD
RANGES CLO DRYERS WTR MTRS 100 ADDR
GAIN, DIV RTA COOK /L!/
CITY TEL NO
DIpWAtN AUTO WIYN STATE
SPACE HTR. STA APP (wH P MAE I SD LICENSE NO I .j
MOTORS, ovSR MOTOVER HP DISTR G Z N P SSEO Y
O 1 100 [
1 a 150 INSPECTION RECORD
a S 200 >
e la 250
11 50 1300
Eo loo 1500
SIGNS. NO TRANS
NO LAMPS
SERVICED SOOV NOT 200A 100
SERVICED SOOV OWR 200 A 200
SERVICE OVER SOOV Soo
MIaC
PERMIT Ia1U1N0 FEC 200
SUPPLEMENTARY PERMIT ISSUING FCC 100
TOTAL FEE 1
I HERSYY ACKNOWLEDGE THAT I HAV[ RKAO THIS APPUCATION PPRGYALB DATE IR cCTo •601
AND STATE THAT THE ANOW IS CORRECT AND AGREE TO COMPLY CONDUIT
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
ELSCTKICAL WIRING WIRING
I HERmY CERTIFY TRAY I Ar PROPERLY REOISTERSD AND/OR
UCEMEED AE REGu EY LOE ANS COURTY AND STATE OF FIXTURES-
CAUFORMIA OR T I AM TIE LE OWNER OF THE ASOW I
OEIQIEED RSAID IA ROKMTY POWER
OF
SIGNATUR
T UTILITYCO NOTIFIED
FINAL
IDATION ARTHUR C vIT
NO CASH SUPERVISING ELECTRICAL ENGINEER
CI� R
�ICp 5 3 3 5 Z FEB 6 2 D 3.4 0 v
WORKERS COMPENSATION DECLARATION 63 ,O,Bt APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self CE�8OeG
insure or a certificate of Workers Compensation Insurance COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified copy thereof (Sec '3800 Lob C )
Policy No Company FOR APPLICANT TO FILL IN JOB
\ ❑ Certified copy is hereby furnished New Residential Bldgs 8 Pools EACH NO .FEE ADDRESS
Z2 ZeAZ:10
❑ 1 8 2-Famd Ft : — f LOCALITY C
Certified copy a fled with the county building mspec Y. S9
hon department , Multi-family Sal Ft — NEAREST
CROSS ST
Dote AppLmm
Residential Swimming Pools OWNER OR
NAME
CERTIFICATE OF EXEMPTION FROM WORKERS ADD
COMPENSATION INSURANCE Outlets Rec�Light_Sw_ MAIL 5�d
(This section need not be completed If the work Involved byy First 20 s
the pormN Is for one hundred dollars ($100)or less ) Total No Additional CITY Tel No
I certify that in the performance of the work for which this APPLICANT
Permit is issued 1 shall not employ any person in any manner
so as to become subject to the Workers Compensation Laws Lighting Fixtures / First 20 DRESS _
Additional
Total No CITY Tel No
Dot A pp1111111 Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APIFLICANT If after making this Certificate of APPLICANT
Exemption you should become subject to the Workers _ Range_ Heater_D W
Compensation provisions of the Labor Code you must forth Oven _ DryerVY M — ADDRESS
with comply with such provisions or this permit shall be Top FAU WH — CITY Tel No
deemed revoked Hood _ Fan _Other_
LICENSED CONTRACTORS DECLARATION l affirm UD ' UfFNSE OR F )2
I hereby arm that I am licensed under provisions of Chapter 9 Disp — Room An Cond 1 REG NUMBE Clou
(commencing with Section 7000) of Division 3 of the Business Power Apparatus B Large Appliances DISTRICT NO PROCE D BY Y
and Professions Code and my license is in full force and effect d
/J/ ) Size 8 Type HP KW KVA or KVAR O
License NumILgDL(i �/` Lic Class - Up to 1 Ind FINAL V
4),
ad
Over 1 to 10 Incl DATE Z g —$¢ VALIDATION
Contra cR Dot Over 10 to 50 Incl FINAL /^ U
❑ I am exempt under Sec - Over 50 to 100 Inc BY U1 c,� �.......� F 6 2 7 2 A 6
B 8P C for this reason Over 100 44
# . . . . . 2 Z
- Services Swbd MCC 8 Ponelboords
Date 0 -200 Amp Under 600 V � 2 • • 3575
Signature 201 - 1000 Amp Under 600 V - -
❑ Over 1000 Amp or Over 600 V ) � ' 3 5 7,5 Exemption for Reg Mamt Elect
SINGLE FAMILY Temp Power Pole 8 Appurtenances µ -0 Z 4—8 3
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License Additional Sign Branch Circuits
for the following reason (Section 7031 5, Business and
Professions Code)
❑ I as owner of theproperty, will do the work and the Msc C8nduits 8 Conductors "
Other See Complete Fee Schedule ►
structure is not intended or offered for sale (Section ( P )— ,
7044, Business and Professions Code)
CONSTRUCTION LENDING AGENCY - —
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued PERMIT FEE (Sub-Total)
(Sec 3097,Civ C )
PIAN CHECKING FEE
Lender's Name I
PERMIT ISSUING FEE __ i
Lender s Address
I certify that I have read this application and state that the TOTAL FEE
above mformation is correct I agree to comply with all County
ordinances and State lawn regulating Electrical wiring and
hereby authorize representatives f this County to enter upon "
the a ve me coned pro eny f r in pection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
aw,wiu
Signature of Permittee Dater