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7111 am" IIY� , • APPLICATION FOR tL{iWi•
DEPARTMENT OF AND sAFETY ELECTRIC i
COUNTY OF LOS LOS M ANGELES
` WILLIAM J. FOX, CHI[r ENGINEER
FOR APPLICANT TO FILL IN DISTRICT NO. OROUP I ZONE PERMIT NO.
ELECTRICIAN T A -1 14121
' RECEIVED SY READY rOR DAT[ IYBU[D
ADDRESS mil/ O r&w !J� v rIR13r INSP[onDN
CITY T, �� J TEL.NQ G
COUNTYLIDENS[ NO EXPIRES Apop ss � S „_-n�r�
PERMIT ru LDCALITY 7I'll 1� i/.w
NUMBER OUTLETS EACH
LIGHT Sc a K"FUT el
DRUGS ST. A#
RECEPTACLEB 6
rDcruREB S OWNER
I WALL SWITONEB 5 D MAIL
ELEP RANGES IId ADOR[BB
[LEC HEAT[RB IIS CITY TEL. NO
NUMBER Or CIRCUITS INSTALL[DI I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS
TQT , i!Vf,40 APPLICATION AND STATE THAT THE ABOVE iB CORRECT
LIMHTQ AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES
MOTORS AND STATE LAWS REGULATING ELECTRICAL WIRING
NYMRCR HORSEPOWER r[[ I DERTIrY THAT 1 POGSESB THE ABOVE VALID LOU
N[w MVD. HP OVER 1MD [ADN ANBELEB COUNTY LICENSE, OR 1 AM THE LEGAL OWNER
Yz A t[rtie III IIS Or THE RLSID[NTIAL ERTY DESCRIBED ABOVL
va II 6O SIGNATURE or
II S 100 P[RMI
S IS 1.50 INSPECTIOWRECOR0
IS SO II SO
BO IIDO S OO
II00 SOO IO OO
SOO IOOO 1S 00 J
OVER 1000 2000 Z
NO GET/MEQ CHANGER-HP
WELDERS AO-KVA Q'
G[NERATORB - KW O
TRANBFORM[RB - KVA
TEMP MOTORS (715Or GRID
MOVED MOTORS (76 Or anis)
m;sc
BIONS
TYPE ND.TRANS
No.LAMPS APPROVALS
rOR EACH PERMITS DAT[ INSP[OTOR•S NAM[
WIRING 411,vo CONDUIT
111XTIJREB 1 00 WIRING
RUPPLEMENTARY so FIKrUR
POWER
TOTAL FEE • / 8~ U71LITYCO NOTlrlm
rINAL jar
WORKERS COMPENSATION ON D consent to CE 8D ,D,e, APPLICATION FOR ELECTRICAL PERMIT /�
I hereby affirm
that I have a certricale d consent to sell iraure eoeO y I
or a certificate d Workers Conpeneatan Insurance or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY Iul
copy thereof(Sec 3800 Lab C 1
Policy No Company FOR APPLICANT TO FILL IN JOB
❑ Certifled copy is hereby furnished New Resdenaal&dBs 8 Pods EACH NO FEE ADORES
❑ derided copy is bled with the county blllfllrnig IrmspeCllOrl
1 8 2-Famdy, SD Ft $ — $ LOCALITY
departmentMuth-famrty Sq Ft — NEAREST
So eLW
CR0&9 ST
Dale Applicant Residential Swunmuig Pools OWNER OR
FPM
CERTIFICATE OF EXEMPTION FROM WORKERS Outlets Rec— Light _ Sw MNL
COMPENSATION INSURANCE ADORE
(This section need not be completed If the work bwolred by the First 20
IN
permR a for one hundred ddlam(5100)orleu) ' Total No Additional Td
I candy that in the performance of the work for which the permit PON CHECK c�
is issued I shall not employ any person in any, manner so as to APPLICANT
become subject to the lyorkem Laws Lighting Frdures Fast 20 ADDRESS
Additional
Date
�lcant i Total No CITY Tel No
NOTICE CANT If after the Ceridcare d Fixed Appliances Not Over 1 HP PERS
Exemption you should become subject to the Workers Compensation flange— Heater_ DW _ APPLICANT
provsions of the Labor Code you must forthwith compy with such Oven _ Dryer — W M — ADDRESS
prwecns or Mn permit shall he deemed revoked Top _ FAU _ WH
LICENSED CONTRACTORS DECLARATIONCITY Tel No
Food _ Fen Other_
I hereby ing that am ficermad under provof to of Chapter B asp _ Roam Air Cord REGN U OR class
(commencing with 3ecirori 7000) of Drvsion 3 d the Buerreas and REG NUMBER
Profeasgrts Coda and my license is in full force and effectDISTRICT NO ED BY
Power Apparatus 8 Largo Appliances o
Size 8 Type HP KW KVA or KVAR SL V// t
lxcenae Number Lc Clava Up to 1 Intl - FINAL
O1 to 10 Incl DATE
so ,0 2 kX
CotractorDate Over 10 to 50 bid F1 'Y�1�5�! 0
I am exempt under Sec Over 50 to 100 In BY
88PC for the reason Over 100 G.
Sernces Swbd MCC d Panelboards # e a e e e 2 to
Date 0-200 Amp Under BOO V 1 • - 2550
Signature 201 - 1000 Amp Under 500 V
E] Exemptionfa Reg Mare Elect Ovar 1000 Amp or Over 800 V e a e 2 5 5 0
1227-87
SINGLE FAMILY Temp Power Pole d Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Grcud
I hereby affirm that I am exempt from the Contractor a License Law
for the following reason(Sectcn 7031 5,Business and Professions Additional Sign Branch Circuits
Code) '
�J I as owner of the property will do the work and the structure Misc.Conduits a Conductors
-\ rs not intended or offered for sale (Section 7044, Business Otter(Sae Complete Fee Schedule)
and Pmfesecre Code)
CONSTRUCTION LENDING AGENCY 8 8 6 6 5 A
I hereby affirm that there is a construction lending agency for the # • • • • • 2
performance of the work for which the permit is awed(Sec 3007 PERMIT FEE (Sub-Total)
Cm C)
PLAN CHECKING FEE
Lenders Name
PERMIT ISSUING FEE
Lerdera Address ,
I certify that I have mad this application and state that the above TOTAL FEE
information s correct I agree to comply with all County ordsarces ,
and State laws regulating Electrical wenng and hereby authorize
representatives of the County to enter upon the above-mentoneG # • • • 2
p
f Inep@d10n1 pUrose8
SEE REVERSE FOR EXPLANATORY LANGUAGE
Turrea Permittee Date