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32151-21A 11-58 APPLICATION FOR-ELECTRIC PERMIT 1
DIVISION OF BUIL MG AND SAFETY
Depmiment of County Engineer BUILDING
Corm{p Of LOB Angeles ADDRESS
6368 Aillf-e-ne-
JOHN A.LAMBIE.COUNTY ENGINEER
CASSATT D.GRIFFIN.SUPT OF BUILDI a LOCALITY Tamy l a Cita
FOR APPLICANT TO FILL IN CROS
srr.
O
ERM FEES
NUMBER OWNER
]A LIGHT OUTLETS MAIL
Z F RECEPTACLES ADDRESS
WALL SWITCHES FEE CITYTEL.NO.
TOTAL OUTLETS @ s¢ $ 11.8
A ELECTRICIAN
�. ELEC.RANGES as •2 ADDRESS
103n N. r7rantivi Aw
].
ELEC.HEATERS Es
EL — CITY TEL.N r
KW MA STATE
FIXTURES g Q LICENSE NO. 7L171407 0--10
MOTORS DISTRICT NO GROUP WNE READY FOR INSPECTION
NUMBER HORSEPOWER FEE
NEW MVD. HP OVER INC. EACH �!
2 Fan ar &&HH ,ag INSPECTION RECORD
14 a .s0
2 s 1.00 �-�
1s so 2.50 F;� f+� /v/ /,s) "�rr e,#,e b
so 200 s.0o
'.
MISC.
6 11OR s/Af K
NO.SIGNS NO.TRANS.
NO.SIGNS NO. LAMPS
FOR EACH PERMIT:
WIRING $1.00
FIXTURES $1.00 1 '
SUPPLEMENTARY .00 APPROVALS
TOTAL FEE Is 5035'. DATE INSPECTOR'S SIGNATURE
THIS APPLICATION
AND STATE THAT TH6EABOVE HB CORRECTREAD AND AGREE 70 JE
CONDUIT pp ✓ f1
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGU - •S G
ELECTRICAL WIRING. /,
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED S - jq X� .
LICENSED AS REQUIRED OS ANGELES COUNTY AND ST
CALIFORNIA_ OR THAT ! AM THE 6A WNE OF THEDESCRIBED It SIDENTIA P ESIGNATURE CO.NOTIFIED
OF P1:RMITTRE
JOHN A.LAMBIE.COUNTY ENGINEER (�ATION ARTHUR C.VEIT..CHIEF ELECT.INSPECTOR
CASH
ao 5 7 :3 0 VAR 4 2
5.3 5 In
WORKER'S COMPENSATION.DECLARATION 20-0019 DPW(12.91) APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self insure, 76A663
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.) / Q pL.Trt�ry p
PoliADDRESS �y��Q Q cy No. Company FOR APPLICANT TO FILL IN �U
Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE LOCALITY
—
F11 &2-Family,Sq.Ft. $ $Certified copy is filed with the county building inspection _ NEAREST 1
department. Multi-family Sq.Ft. CROSS ST. LDW&DON
Date Applicant Residential Swimming Pools ASSESSOR
MAP BOOK + u PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec._Light Sw. FIRM NAME t�OH NIJ WMA
COMPENSATION INSURANCE
(This section need not be completed If the work Involved by the First io MAIL
permit is for one hundred dollars($700)or less.)
Total No. Additional ADDRESS (y241� VEL LOMA
I certify that in the performance of the work for which this permit CITY SAN &A469 I F_L Tel.N..$111 451-&'7lp2
is issued, I shall not employ any person in any manner so as to PIAN CHECK
become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 APPLICANT
Total No. Additional
ADDRESS
Date Applicant RESIDENTIAL APPLIANCES NOT OVER 3 HP.
NOTICE TO APPLICANT: If, after making this Certificate of CITY Tel.No.
Exemption,you should become subject to the Workers'Compensation OTHER APPLIANCES NOT OVER 3 HP.
provisions of the Labor Code, you must forthwith comply with such PERMIT
provisions or this permit shall be deemed revoked. Power Apparatus&Large Appliances APPLICANT
LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS
I hereby affirm that I am licensed under provisions of Chapter 9 Over 3 to 10 Incl.
(commencing with Section 7000) of Division 3 of the Business and CITY Tel:No.
Professions Code,and my license is in full force and effect. Over 10 to 50 Incl. }
LICENSE OR Class.
Over 50 to 100 Incl. REG.NUMBER 0.
License Number LiC.Class Over 100 DISTRICT NO. �h PROCESSED BY 0
Services,Swbdy MM C&��P,�s�r gl o�(a,s i � �i t� � "�.— It
Contractor Date 0-;i ^"'p•„"„er110 " DATE 0
❑ I am exempt under Sec. 400-1000 Amp.Under 600 V VALIDATION V
Over 1000 Amp,or Over 600 V FINAL UId
B.&P.C.for this reason BRANCH CIRCUIT FEES BY
Date: 15A,or 20A,120V,Lighting or Recept. Z
1 To 10 Branch Circuits
Signature 11 To 40 Branch Circuits
❑ 41 Or More Branch Circuits � (. °4
Exemption for Reg.Maint.Elect. 15A,20A,208V To 277V Lighting Br.Circuits
SINGLE FAMILY Temp.Power Pole&Appurtenances 3��7 N.55
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License Law
for the following reason(Section 7031.5, Business and Professions Additional Sign Branch Circuits
Code): TOTAL 59 -55
I,as owner of theConduits&Conductors Misc
ro ert ,will do the work and the structure . r's
P P Y ����p5-5
is not intended or offered for sale(Section 7044, Business Other(See Complete Fee Schedule) u A�r-�
and Professions Code). ® �:HALAL °cri
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 (Sec. 3097, PERMIT FEE (Sub-Total) 00001r
01001 10/30/9'2
Civ.C.)
54
PLAN CHECKING FEE 5� � 1 AM i°
Lender's Name
PERMIT ISSUING FEE
Lender's Address
I certify that I have read this application and under penalty of purjury.state TOTAL FEE
that the above Information is correct I agree to comply with all County
ordinances and State law gulating Electrical wiring,and hereby authorize
represanta' es of this C ty to enter upon the above-mentioned property
f 7nstl� purposes. n SEE REVERSE FOR EXPLANATORY LANGUAGE
– _ 2
SIGN RE F PERMITTE DATE '