HomeMy Public PortalAbout4916 ARDSLEY DR_Electrical__ WORKER'S I have
a certificate
DECLARATION 20-0019 DPW(12-91) /Y#PI UCA II �®llV' FOR-ELEC u ROCAL�- PERN� I I
Y 76A663 - (� u�u ).f
�1 hereby affirm that Lhave a certificate of consent to self insure, ,
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.),"
PolicyNo. Company FOR APPLICANT TO FILL IN d ' JOB- (� / 7-cv"J/e
El' Certified
P YADDRESS -�'l tJ�S�'C ,/✓lr Cts
Certified copy is hereby furnished. New Residential,Bldgs.&.Pools NO. EACH FEE LOCALITY LCL
1 &2-Family,Sq:Ft:" — $ $
❑. Certified copy is filed with the county building inspection NEARESTdepartment. Multi-family Sq:Ft.t"— — CROSS SL
Date` Applicant Residential Swimming Pools ASSESSOR
MAP BOOK PAGE PARCEL
CERTIFICATE OF EXEMPTION.FROM WORKERS'-, OWNEROR
COMPENSATION INSURANCE Outlets:Rec._Light Sw. FIRM NAME �'G�QT" G}r�G✓G
First 20 MAIL
(This section need not be completed if the work involved by the 1(6 1>r-
permit Is for'one hundred dollars($1.00) Total No. Additional ADDRESS �lfit5 orlessi) ,
I certify that-:in the performance of the work for'whlch this permit CITY ,&, C��t� -_ Tel.No.7_57- 2917
.is issued, I shall not employ"a ny'peison in'any manner so'as t0 "
becomePLAN CHECK
.subject the Workers',Compensation Laws.. Lighting Fixtures First 20 PLAN CHECK
_ Total No. Additional
2J ^CT 5 ADDRESS
Date"S- O Applicant t +"✓�e� �'t�C`1 RES]DENTIAL:APPLIANCES NOT OVER 3 HP. -
NOTICE TO APPLICANT: If;, after making-this Ce tificate of CITY - Tet.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 suchPERMIT �` 1
provisions or this permit shall be deemed revoked. Power Apparatus&Large Appliances nPPLICANT 1 J� F1,1 Je
LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS( 7 3 rb9d•F'1rCr C ,
I hereby",affirm that I am licensed under provisions•of Chapter..9 Over 3 t6'10 Incl. ,A
(commencing with Section 7000) of-Division 3 of the Business and CITY" i Tel.Nolj 52-0'31-1
Professions Code,and my license is in full force and effect. Over 10 to 50 Incl.
Over 50 to 100 Incl LICENSE OR �7 7� C 1 Q >
- REG.NUMBER L Class.
/' •� / .. a
License Number C-1 O 6 Z 5 r `�-) Lic:Class �•-� 1`� Over'100 DISTRICT NO. Q ESSED BY - O
Servi Swb M C P el ards �0 rt
Contractor`. �`� 1nr�cy -Date S"Z'� 5 Op. UnO V DA7e 0
400-1000 Amp.Under 600 V
❑ I am exempt under Sec. VALIDATION - V
Over 1000 Amp.or•Over. 600,V
FINAL W
B.&P.C.for this reason• B ANCH CIRCUIT FEES BY a
(/)
Date: 15A,or 20A, 12DV,Lighting or Recept. - Z
- 1 To 10 Branch Circuits
Signature
11 To 40 Branch Circuits
Exemption for Reg.Ivlaint.Elect41 Or More Branch Circuits. 15A,.20A,208V To 277V Lighting Br.Circuits.,
°
SINGLE FAMILY Temp. Power Pole&Appurtenances
HOMEOWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from"the Contractor's License Law Sign with One.erahch Circuit _���_
for,the following reason (Section 7031.5,Business and Professions Additional Sign Branch Circuits i=i =
Code): - ��
I, as owner of.the property,will do the work and the structure Misc.Conduits&Conductors
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule)
and Professions Code. b D. -•'t^,•:,
1_.
,i .
i. t,i a•_.r. _
CONSTRUCTION LENDING AGENCY
Thereby affirm that there is a construction lending agency for the _
performance of the work for which this permit is issued Sec. 3097, 001 :-Fi 95
p P ( PERMIT FEE " (Sub-Total) I j�L i`� -1 - `'
Civ. C.) ,+t1-`.• - ":@ _
a: t nTr.
PLAN CHECKING FEE '' "' •
Lender's Name
PERMIT ISSUING FEE
Lender's AddressTOTAL FEE
I certify that I have read this application and under penalty of purjury state Lf
that the above information is correct. I 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
fo tion SEE REVERSE FOR EXPLANATORY LANGUAGE •
.5 [J�
IG URE OF PERMITTEE DATE -
' - COUNTY OF LOS ANGELES TEMPLE CITY # 0508 ELECTRICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS EL 0508 0404050006
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
LEGAL-ID: FEES PAID BUILDING ADDRESS:
TR: 14647 LT: 44 4916 ARDSLEY DR
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917803803
ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET: TEMPLE CITY BLVD.
8590-016-008 Al PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 597- GRID:.-A5 -LOCALITY: TEMPLE CITY, C
G1 OUTLETS-LGT,SW,RECP 47.00 OUT 75.45
TENANT: G2 LIGHTING FIXTURES 12.00 LGT 23.40 ISSUED ON: PROCESSED BY: PLAN BY: EXPIRES ON:
HA FAU LESS 3HP 1.00 FAU 10.95 04/06/04 VG 10/03/04
H2 RES GRBG DISP LT 3HP 1.00 DIS- 10.95
OWNER: TEL. NO: H3 RES DISHWASHR LT 3HP 1.00 DIS 10.95 FI L D BY: CODE:
APARICIO, RICHARD/GINA (626) 287-2917- H4 RES RANGE HDS LT 3HP 1.00 H00 10.95 ��
4916 ARDSLEY DR H5 RES WASH MACH LT 3HP 1.00 WAS 10.95
TEMP 917803803 H7 RES EXHAUST FANS - 1.00 EX 10.95 DESCRIPTION OF WOR
H9 RES APPL LT 3HP 1.00 RES 10.95 ELECTRICAL FOR ADDITION
JB.AC UNITS +3-10HP 1.00 AC 19.65
APPLICANT: TEL. NO: TOTAL FEES 222.90
APARICIO (626) 287-2917-
SPECIAL CONDITIONS:
CONTRACTOR: TEL. NO: APPROVALS DATE INSPECTOR SIGNATURE
TOM O'LEARY CONSTRUCTION (626) 287-0927-
5823 AGNES AVENUE LIC. NO TEMPORARY POWER POLE
TEMPLE CITY, CA 91780 489354 B-1
UNDERGROUND CONDUIT
ARCHITECT OR ENGINEER: TEL. NO: UFER GROUND
IMPELLIZZERI, FRANK (626) 286-6901-
437 N. PINE ST. LIC. NO: ROUGH CONDUIT
SAN GABRIEL, CA 91775 NONE
ROUGH WIRING
MAIN WATER LINE /
PLASTIC Y/N METAL Y/N
UTILITY COMPANY NOTIFIED
REPORT ID: DPR265 ROUTE TO: BS0508
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 ELECTRICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS EL 0508 1308060009
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
(LEGAL ID: 1 FEES PAID BUILDING ADDRESS:
ITR: 14647 LT: 44 1 1 4916 ARDSLEY DR 1
I IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT: ( TEMP CA 917803803 1
(ASSESSOR INFORMATION NUMBER: I I NEAREST CROSS STREET: TEMPLE CITY BLVD. 1
18590-016-008 JAI PERMIT ISSUANCE FEE 27.80 1 THOMAS PAGE: 597 GRID: A5 LOCALITY: TEMPLE CITY, Cl
I IG1 OUTLETS.-LGT,SW,RECP 1.00 OUT 2.00 i I
(TENANT: IH7 RES EXHAUST FANS 1.00 EX 11.00 (ISSUED ON: PROCESSED BY: PLAN BY: 1
1 TOTAL FEES 40.80 108/06/13 SR I
I I I I
(OWNER: TEL. NO: 1 IFI.DJAL DATE FINAL BY: CODE: I
IAPARICIO, MR&MRS RICHARD
14916 ARDSLEY DR - 1
1TEMP 917803803 1 ID C.IPT ON OF WORK
I I ZONE RECEP AND EXHAUST FAN
I
1APPLICANT: TEL. NO: 1
1O'LEARY, TOM (626) 287-0927- 1
15823 AGNES AVE i ISPECIAL CONDITIONS:
(TEMPLE CITY CA 91780 1
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ICONTRACTOR: TEL. NO: 1 (APPROVALS DATE INSPECTOR SIGNATURE
ITOM O'LEARY CONSTRUCTION (626) 287-0927- I _
15823 AGNES AVENUE LIC. NO j TEMPORARY POWER POLE
ITEMPLE CITY CA 91780 489354 1 1 1
I 1UNDEP.GROUND CONDUIT I I I
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1ARCHITECT OR ENGINEER: TEL. NO: 1UFER GROUND
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1 LIC. NO: 1 (ROUGH CONDUIT I I I
I I
1 (ROUGH WIRING 1
IMAIN WATER LINE 1 1
1 IPLASTIC YIN METAL YIN I I
- - (UTILITY COMPANY NOTIFIED(
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1 I* ADDITIONAL DATA ON FILE 1
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I (REPORT ID: DPR265 ROUTE TO: BS0508