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7SA6E 1CjE446�62 APPLICATION FOR ELECTRICAL PERMIT
COUNTY OF LOB ANGELE8
DEPARTMENT OF COUNTY ENGINEER FA.13CALITY
ILDING
BUILDING AND SAFETY DIVISION RESVO
JOHN A LAMBIE, CouNTT ENGINEERWILLIAMA JENSEN SUPT or SUILDINa
NEAREST
FOR APPLICANT O FILL IN CROSS e'f
RECEPT TOTAL Ho [ACH PEE
OUT FIRST 20 $204 OWNER E C/CE
LIGHT MAIL
!WITCH OVERADD20 10 ADDRE6$
02 TOTAL CITY TEL NO -S 7
LIGHTING � Ftner 20 a0
PL
FIXTURES ADD2 10 ELECTRICIAN
oV n 20
RAND[[ uo mymm W R HTRE 100 ADDRESS
GARS DISP RA COO[
clrr TEL No
DIWWAeN AUTO WA401 STATE
SPACE emu RA AM (K N P MAI ) 50 LICENSE NO
MOTORS. ov[R NOTOV[R HF DID1 G E P
O 1 1100
1 — a 150 J INSPECTION RECORD
3 — a 200 ����; nl ^n•,0, .LGi�, D,4'PL;��..
a 1a Sao
18 SO 300 • `i • - G
30 — 100 a oo ,.� ,B/ � 0
/
BIONS. NO TRANS �y /�/� O<
NO LAM►. TI �Q V' kO
SERVICE O 600V NOT OVER 200A 100 0j
6
SERVICE nOOV OVER 200A 200 � v�
SERVICE OVER a00V goo
MISC
PERMIT ISSUING PEE 200
SUPPLEMENTARY PERMIT ISSUING FEE A";D �AjWOF
TOTAL FEE
I N[RE[T ACRNOWL[DO[ THAT 1 HAVE RtwD ATIOH LS DAT[ IMQ[ ma SIGMA m
ANO RAT[ THAT THE ABOVE 1[ mRRII= AHD AMPLY (ANDUIT
Wm1 ALL COUNT OROINANCU AND rtAT[ LTIND
EL[RIIICAL WIRING WIRING
I HERYY artIFY THAT I AM PROPERLY REDIOR
L10ERSm AR REQUIRED eY LOE wnG[LER COUNTY [ of FURU RESCALIFORNIA OR THAT I AM THE LEGAL OWNEROV[RESIDENTIAL FPOWaR fI
SIGNATURE ` s
OF PERMITTlE UTI LI CO NOTIFIED �[
FINAL
—VALIDATIONA R c VEII
MOOCAS CAYN SUPERVISINGELECTRICAL ENGINEER
Vj,07 1 5 9'� 1tiU131 2 D 4.60-
;6�
V/QRVERS'COMPFNSATION DECLARATION CE-806G (2 BO) APPLICATION FOR ELECTRICAL PERMIT
i hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY
insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec 3800LobC)
Policy No (oao�a4 Compan t 6 't FU FOR APPLICANT TO FILL EACH N JOB
NO FEE ADDRESS U�/1J
New Residential Bldgs &Pools �"
Certified copy is hereby furnishad 1 &2 Famdy,Sq Ft E — 9 LOCALI TV
Certified copy n filed with the county building inspection Multi family Sq Ft ` CROSS 97
department Residential Swimming Pools OWNER OR
��������{Q���PQnt��! - FI RM NAME��/
Aid
Dateli!L.LSILS� Applicant 5 Outletr Rec—Light st 20 t ADDRESS OJ`i�
CERTIFICATE OF EXEMPTION FROM WORKERS' Total No Additional CITU Tel No —5 }
COMPENSATION INSURANCE
I- PLAN CHECK p
(Thu section need not be completed if the work mvOWed APPLICANT U
by the permit u for one hundred dollars ($100) or leu) Lighting Fixtures First ADDRESS (E
Total No Additional C
I certify that'ln the performance of the work for which this CITY Tel No 0
permit is Issued I shell not employ any person in any manner Fixed Appliances Not Over 1 HP
PERMIT
so as to become subject to the Workers' Compensation Lave Range_Heater_D WAPPLICANT 0. d
• Oven — Dryer_W M _ ADDRESS 2
in
' Top _ FAU _W H
Date Applicant - ^
Hood _ Fen _Other_ CITY Tel No IJ
NOTICE TO APPLICANT If after making this Certificate of Disp _ Room Air Cond_ L CENSE OR / TT-7�
Exemption you should-become subject to the Workers' REG NUMBER 6 Clap Q
Compensation provisions of the Labor Code you must forth Power Apparatus& Large Appliances DISTRICT NO P CES ED BY
with comply with such provisions or this permit shall be ^
deemed revokedSize&Type HP KW,KVA,or KVA 0 u
Up to 1 Incl 11 !/
Over 1 to 1 O Incl DATE VALIDATION
LICENSED CONTRACTORS DECLARATION Over 10 to 50 Incl VALIDATION
1 hereby affirm that 1 am licensed under provisions of Chapter Over 50 to 100 Inc FIN
9 (commencing with Section 7000)of Division 3 of the Bust Over 100 BV
ness and Professions Code, and my license u in full force and
effect n Services
License Nu bar Lic Clem-
de) 0-200 Amp Under 800 V
/� 'rte 201 1000 Amp Under 800 V •
Contracto Data l0 a y7l Over 1000 Amp or Over 800 V
HOMEOWNER BUILDER DECLARATION Temp Power Pole&Appurtenances.
1 hereby affirm that 1 am exempt from the Contractor's Sign with One Branch Circuit
License Law for the following reason (Section 7031 5, Bust Additional Sign Branch Circuits
nese and Professions Code) ConConductors $2 3 5 4 A
Misc Conduits&Conductors
Ell. as owner of the property will do the work and the Other (See Complete Fee Schedulel—
structure u not intended or offered for sale (Section # e,e • • • 2
7044, Business and Professions Code) ,
CONSTRUCTION LLNDING AOLNCY ) - 3250
I hereby affirm that there u a construction lending agency
for the performance of the work for which this permit is PERMIT FEE (Sub-Total) p7 • - - .32505
issued(Sec 3097 Civ C) '
Lender's Name PLAN CHECKING FEE (One Fourth Permit Fee) 06627785
Lender s Address PERMIT ISSUING FEE . r i
I certify that I have read this application and state that the TOTAL FEE /
above information is correct 1 agree to comply with all County
ordinances and State laws regulating Electrical wiring, and
hereby authorize representatives of this County to enter upon
the above mentioned property for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
,t,3&b �tltLL /8
Signature of Permrttae De i