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` COUNTY OF LOS ANGELES - APPLICATION FOR PERNIIT
DEPARTMENT OF COUNTY ENGINEER
�T^ DIVISION OF BUILDING& SAFETY ELECTRIC 1
WILLIAM T. FOB, COUNTY ENGII M
FOR APPLICANT TO FILL IN DISTRICT NO. GROUP ZONE PERMIT NO.
ELECTRICIAN WROBERTS ELFmRir
ADDRESS . IDAHO STREET RECE[ ED BY READY FOR DATE ISSUED
ya. FIRST'INSPECTION 9
CITY r TE NO. �r �Z�f/�/u �') �// ' T
COUNTY LICENSE NO. EXPIRES BUILDING ��
PE&M FEES ADDRESS
.
NUMBER F-ACH FEE LOCALITY
LIGHT OUTLETS NEARSTE ¢
RECEPTACLES O
WALL SWITCHES OWNE147
TOTAL OUTLETS Sc 8 MAIL
ELEC. RANGES 2S ADDRESS
ELEC. HEATERS. '25
FIXTURES 5 CITY TEL. NO:
MISC. 1• HEREBY ACKNOWLEDGE THAT I HAVE READ THIS
NUMBER OF LIGHT CIRCUITS r/yS APPLICATION AND STATE THAT THE ABOVE IS- CORRECT
1 AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES
NUMBER OF RECEPTACLE CIRCUITS AND STATE LAWS REGULATING ELECTRICAL WIRING.
MOTORS I CERTIFY THAT. 1 POSSESS THE ABOVE VALID LOS
NUMBER HORSEPOWER FEE ANGELES COUNTY E, OR I AM THE LEGAL OWNER
NEW MVD. HP OVER INC. �Ox OF THE RESIDENT[ OPE t.Y 7RRIlte ABOVE.
SIGNATURE
Vs e 2 '50 ,
2 i 5 1.00 DiSPECTION BECOBD
s is 1.50
so 50 2.s0
50 200' 5.00
200 Boo 10.00 J
Boo too0 15.00
OVER1000 20.00
M.G. SET/FREQ. CHANGER-HP., a
WELDERS: AC-KVA 0
GENERATORS•'KW•
TRANSFORMERS-KVA
TEMP.' MOTORS (75% OF-ORIG.)
MOVED MOTORS (75% OF CRIS.`)
MISC.
SIGNS
NO.' NO.TRANS.. APPROVALS
NO. NO. LAMPS
FOR EACH PERMIT: DATE INSPECTOR'S NAME
WIRING $1'..00 CONDUIT
FIXTURES $1.00 WIRING
SUPPLEMENTARY gp FIXTURES
POWER
TOTAL FEE $ UTILITY CO. NOTIFIED
FINAL f l�
76A,663 D38# 8A. 4-88 - -
WORKERS'COMPENSATIONDECLARATION • ?6A663 APPLICATION FOR ELECTRICAL, PERMIT'
CE-806G (2.80)
I hereby affirm that I,have a certificate .of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY
insure,or a certificate of Woikers'Compensation Insurance,or /
a certified copy thereof(Sec.3800,Lab.C.)
H FOR APPLICANT TO FILL IN JOB
Policy No. Company ADDRESS
New Residential Bldgs`.&Pools EACH NO. FEE
❑' Certified copy is hereby furnished: 1 &2-Family,Sq.Ft. $ — $ LOCALITY
❑ , Multi-family Sq. Ft. NEAREST
Certified•copy is filed with the county building inspection CROSS ST
department. I •Residential Swimming Pools OWNER OR '
FIRM NAME Zk r—
Date Applicant ;Outlets: Rec.l;LLight�_Sw._�20 Q MAIL /
CERTIFICATE OF,EXEMPTION FROM WORKERS' Total NoFirst. Additional ' ADDCITY Tel
meTel No.l No. �f
/�1
COMPENSATION INSURANCE —e
7, PLAN CHECKVCL
(This section need not be completed if the work,involved GQ APPLICANT V
by the permit is for one'hundred doliats• ($1.00) or less.) Lighting Fixtures First io• ADDRESS
IZ
Total No. Additional"
I certify that in,the performance of the,work.for which this Fixed Appliances Not Over,1 HP CITY Tel No. F- ,
permit is.issued,I shall not employ.any person in any manner l PERMIT' W
so as-to become subject to the Workers Compensatibn Laws. Range_Heater D.W._ APPLICANT.A&A oe
1 Oven _ Dryer_W.M.— ADDRESS
U)
Date Applicant. O1r7� Top _ FAU, _W.H.._
Hood Fan _.Other,_ 'CITY ..L jWOaT Tel No.
NOTICE TO APPLICANT: If, after making this Certificate of 1 Disp: _Room Air Condom LICENSE OR
Exemption, you should become subject to the Workers' REG.NUMBER Class —/d
Compensation provisions of the Labor Code, you must forth- Power Apparatus&Large Appliances DISTRICT NO. PR.00E SE,D'BY'
with comply with such provisions or this permit shall be ' 1 , r
deemed revoked. , Size&Type HP,KW,KVA,or'KVAR ���
Up to 1 Incl. Wd
'FINAL g
LICENSED CONTRACTORS DECLARATION Over 1 to.10 Incl. DAT V
Over 10 to 501ncl. %A-;;3
, �;°;' VALIDATION
I hereby affirm that I am licensed under provisions of Chapter , Over 50 to.100 Inc. FI
9 (commencing with Section 7000)of Division 3 of the Busi- Over 100 `
ness and Professions.Code,and my license is in full force and
effect. ServicesAr
License Number ;19,2011-11Lia Class— e-—t y 0-200 Amp.Under 600 V
201-1000 Amp.Under 600 V
Contractor ate .5-3—.R-'?i Over 1000 Amp.or Ovbr 600 V
HOME OWNER-BUILDER DECLARATION Temp.Power Pole&Appurtenances.
.'Sign with One Branch Circuit
I hereby'affirm that I arri exempt .from the Contractor's I e
License 'Law for the following reason (Section 7031.5, Busi- Additional Sign Branch.Circuits
ness.and Professions Code):
. .�Misc.Conduits&Conductors
I, as owner'of the property, will do the work and the Other(See Complete Fee Schedul.e)— G 7J a+0 A
structure is not'intended or offered for sale (Section )
7044,Business and Professions Code). I # 0 0 0 0 o. 2
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction-lending agency 2 - 2890
for the performance'of the work for which this permit-is PERMIT FEE (Sub-Total) dA
issued(Sec.3097,Civ.C.). 0 0 0
Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee) 2 9
Lender's Address PERMIT ISSUING FEE Q 3.0 3—8 2
I certify that I have read this application.and state that the iTOTAL FEE a
above information is correct.I agree to comply with all County
ordinances and State laws regulating Electrical wiring, and ti
hereby authorize representatives of this County to enter upon
the ove-mentioned property for inspection purposes. ; SEE'REVERSE FOR EXPLANATORY LANGUAGE
ignature of Per rttee. Date
1