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Home My Public Portal About5017 CLOVERLY AVE_Electrical__ 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 the'r eof(Sec.3800 Lab. C.) Policy No. Company FOR APPLICANT TO FILL IN JOB ADDRESS rZ NO. EACH FEE 1 V d G" Al Certified copy is hereby furnished. New Residential Bldgs.&Pools t &2-Family,Sq.Ft. $ $ LOCALITY /� sJ ❑ IE Certified copy is filed with the county building inspection NEAREST department. Multi-family Sq.Ft. CROSS ST. v Date Applicant Residential Swimming Pools ASSESSOR PAGE PARCEL CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec._Light Sw. _ FOWNER OR RM NAME COMPENSATION INSURANCE First 20 MAIL (This section need not be completed if the work in olved by the Total No. Additional ADDRESS permit is for one hundred dollars($100)or less.) I certify that in the performance of the wor for permit CITY Tel.No. S-71 is issued, I shall not employ any perso o as to PLAN CHECK become sub, t to t e Workers' Comp L Lighting Fixtures First 20 APPLICANT Total No. Additional ADDRESS v Date r Applican, RESIDENTIAL APPLIANCES NOT OVER 3 HP. NOT TO P LICANT: If, a t m g his tertifica e of CITY Tel.No. Exemption, ou should become subject to the Workers'Compensation OTHER APPLIANCES NOT OVER 3 HP. provisions of the Labor Code, you must forthwith complywith Such PERMIT /L12 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. Z `Z g_ Professions Code, and my license is in full force and effect. Over 10 to 50 Incl. License Number�y� " Lia Class 4 Over 50 to 100 Incl. LICENSE OR Class. IL REG.NUMBER FL 1/1-5 Over 100 DISTR��O. i Services,Swb�d., CC&Panelb rds l� ' l ltL Contractor (� � � 2 U Date C •� �� g99fnef 600 p FINAL S DATE❑ �/ J I— I am exempt under Sec. 400-1000 Amp. Under 600 V • W Over 1000 Amp.or Over 600 V FINAL / ALIDATION B.&P.C.for this rea n �1 BRANCH CIRCUIT FEES BY 15A,or 20A, 120V,Lighting or RecepL Z 1 To 10 Branch Circuits Signature 11 To 40 Branch Circuits ❑ 41 Or More Branch Circuits Exemption for Reg.Maint. Elect, 15A,20A,208V To 277V Lighting Br.Circuits SINGLE FAMILY Temp. Power Pole&Appurtenances HOME OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit sem' i ■T for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits Code): ❑ I, as owner of the property, will do the work and the structure Misc.Conduits&Conductors S Lf is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) , OTAL 6'31moi» and Professions Code). C. E' _�a ter•: CONSTRUCTION LENDING AGENCY �i1 ��gg_C »_ I hereby affirm that there is a construction lending agency for the (.:11ANCI performance of the work for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total) r� Civ.C.) Lender's Name PLAN CHECKING FEE 0iDu�-)"LIrt-`_I,r 1 PERMIT ISSUING FEE . 1� 1 r 0. 227 Lender's Address f �r 7� I certify that I have re this applic and under penalty of purjury state TOTAL FEE (v that the abov info ation c rect. I agree to comply with all County ordinan d t law g ating Electrical wiring,and hereby authorize repre , o is ounty o enter upon the above- entioned pro rty for n rp lr SEE REVERSE FOR EXPLANATORY LANGUAGE G)ATUR E 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, 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.) Policy No. Company FOR APPLICANT TO FILL IN JOB ADDRESS Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE LOCALITY ❑ 1 &2-Family,Sq. Ft. — $ $ Certified copy is filed with the county building inspection _ NEAREST department. Multi-family Sq.Ft. CROSS ST. Date Applicant Residential Swimming Pools ASSESSOR MAP PAGEOR PARCEL CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec._Light Sw. FFIIRM NAME COMPENSATION INSURANCE First 20 AIL (This section need not be completed if the work involved by the ADDRESS permit is for one hundred dollars(5100)or less.) Total No. Additional I certify that in the performance of the work for which this permit CITY Tel No. is issued, I Shall not employ any person in any manner so as to PLAN 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 p y 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 rel.No. D. Professions Code,and my license is in full force and effect. Over 10 to 50 Incl. LICENSE OR Over 50 to 100 Incl. REG.NUMBER Class. V Over 100 DISTRICT NO. PROCESSED BY W License Number Lic.Class J Services,Swbd.,MCC&Panelboards LL 0-399 Amp. Under 600 V FINAL }� Contractor Date DATE ❑ 400-1000 Amp. Under 600 V I am exempt under Sec. VALIDATION Q ' Over 1000 Amp.or Over 600 V FINAL cc B.&P.C.for this reason BRANCH CIRCUIT FEES BY fl Date: 15A,or 20A, 120V,Lighting or Recept. 1 To 10 Branch Circuits W Signature 11 To 40 Branch Circuits ~ El 41 Or More Branch Circuits Exemption for Reg.Maint.Elect. 15A.20A,208V To 277V Lighting Br.Circuits SINGLE FAMILY Temp. Power Pole&Appurtenances 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): ❑ 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). 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) Civ. C.) PLAN CHECKING FEE 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 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 SIGNATURE OF PERMITTEE DATE 76A663-CE606 9-6 _.6 APPLICATION FOR ELECTRICAf PERMIT r .WUNTY'OF LOS ANGELES DEBRLDING AND SAOFETY UNTY DIV STONER BUILDING UIFADDRESs 5017 Cloverl JOHN A LAMBIE, COUNTY ENGINEER COLEMAN W. JENKINS, SUPERINTENDENT OF BUILDING Temple Cit FOR APPLICANT TO FILL IN CROSS ST Lower Azusa RECEPT. 4 TOTAL NO EACH FEE OUTLETS FIRST 20 4 $ 20 $ 80 OWNER LIGHT J} ,1 ADD L MAIL 4 SWITCH 1O ADDRESS 5017 Cloverly OVER 20 TOTAL FIRST 20 20 CITYTemple City TEL NO LIGHTING FIXTURES FIXTURES ADD L OVER 20 10 CONTRACTOR Con lee & Son electric RANGES DRYERS WTR HTRS 100 ADDRESS 1030 N. Grandview Ave. GARB DISP STA COOK cITYs San Gabriel TEL No 280-2007 DISHWASH AUTO-WASH STATE SPACE HTRS STA APPL 50 LICENSE NO 242432 MOTORS OVER NOT OVER H P DISTRICTY. G P ZqN O D O 1 100 1 3 150 INSPECTION R CORD s a 200 8 15 250 15 50 300 a O 50 100 500 LJ SIGNS NO TRANS OC NO LAMPS O - G SERVICE 0.600V-NOT OVER 200A 1 100 00 93- SERVICE SERVICE 0.60OV-OVER 200 A 1200, In Z SERVICE OVER 600V 500 OTHER (SEE COMPLETE FEE SCHEDULE) Re-locate -existinci Service PERMIT ISSUING FEE 200 2 00 SUPPLEMENTARY PERMIT ISSUING FEE 1,00 APPROVALS DATE INSPECTOR'S SIGNATURE TOTAL FEE 3 8O 1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION UNDERS LAB WORK AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY ROUGH CONDUIT WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ELECTRICAL WIRING WIRING I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR FIXTURES LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF AND INTEND TO POWER RESIDE IN,THE ASOV ESCRIBED RESIDENTIAL P PERTY (p / SIGNATURE UTILITY CO NOTIFIED �'f��fr7 OF PERMITTEE FINAL _p++" VALIDATION JOS PH C ROOHAN CK MO CASH SUPERVISING ELECTRICAL ENGINEER <' LAW 9 1 1 0`3 JUN 15 2 0 3 B 0- i b 76A683-CE806 3-84 APPLICATION FOR ELECTRICAL PERMIT COUNTY OF LOS ANGELES DEPARTMENT ER BUILDING BUILDING AND SAFETY DIVISIONADDRESS t JOHN A. LAMBIE, COUNTY ENGINEER ��L. WILLIAM A JENSEN, SUPT OF BUILDING LOCALITY / mJf I NEAREST FOR APPLICANT TO FILL IN CROSS ST /C o RECEPT TOTAL NO, EACH FEE / OUTLETS FIRST 20 y�o $20 s OWNER ()C 1 U �c��tJS �' t7 LIGHT `J OVER L > .10 3 / ADDRESS o � so �1? SWITCH Y LIGHTING TOTAL F1Rs7 20 .20 CITY aL �fTEL. NO. �n? y� �� e FIXTURES 1 ADD�L 10 ELECTRICIAN FC / / t OV R 2O RANGES CLO DRYERS WTR.HTRS. 1.00 ADDRESS V V V GARB.DISP. STA.COOK CITY No. DISHWASH. AUTO.-WASH STATE f'/'(7 'C/ J SPACE HTRB BTA.APP.(,/,N P.MAX ) LICENSE NO..8O '� ' MOTORS, OVER NOT OVER HP. DISTWT NO. TUP kjONE I PROCESSED BY O 1 1.010 1 s 1.50 INSPECTION RECORD s e 2.00 h A /.(�vq �a�� !�' ' o 8 15 2.50 /dam "a d' lrJit ' 18 80 8.00 ' - /!� o 80 100 8.00 W CLN SIGNS, NO.TRANS Z NO.LAMPS SERVICE O-SOOV-NOT OVER 200A 1.00 SERVICE O-SOOV-OVER 200 A. 2.00 SERVICE OVER SOOV 5.00 MISC. PERMIT ISSUING FEE 200 SUPPLEMENTARY PERMIT ISSUING FEE 1 00 TOTAL FEE 1HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION APPROVALS DATE INSPECTOR'S SIGNATURE AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CONDUIT ! WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ELECTRICAL WIRING WIRING I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR g LICENSED AS REQUIRED BY L08 ANGELES COUNTY AND STATE OF FIXTURES D 47J CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE DESCRIBED RESIDENTIAL i Y POWER p i SIGNATURE UTILITY CO NOTIFIED 4� P LtJ 1 OF PERMI' FINAL �(7 V LIDATION ARTHUR C. VEIT SUPERVISING ELECTRICAL ENGINEER CK MO CASH L� 5259-0 OCT 26 2 D 15.20 WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12-91) APPLICATION FOR ELECTRICAL PERMIT ,I hereby affirri�that 1 have a certificate of consent to self Insure, 76A663 or a 6'ertificate 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) . t JOB POIIC NO • Company FOR APPLICANT TO FILL IN ADDRESS \ o ❑ y P Y ��/l LLU 'l � * NO EACH FEE Certified copy Is hereby furnished New Residential Bldgs &Pools LOCALIT ❑ 1 &2-Family,Sq Ft $ $ "J 'Certified copy Is filed with the county budding inspection _ NEAREST department Multi-family Sq Ft CROSS ST b S` Date' Applicant Residential Swimming Pools MAPEBOOK O� Q PAGE PARCEL CERTIFICATE OF EXEMPTION FROM WORKERS- Outlets Rec/Light. �_ Sw < / FIRMOWNER OR NAME' COMPENSATION INSURANCE First 20J �'^ (This section need not be completed If the work Involved by the Z ADDRESS MAIL permit is for one hundred dollars($100)or less) Total No Additional I cert fy that in the performance of the.work for which this permit AV---Ir CITY IZ_ Tel No K;— 4, is Issued, I shall not employ any persn In any" nner s as o �. PLAN CHECK become subject.to the Workers' Compensati s Lighting Fixtures First o APPLICANT Total No Additional ADDRESS Datez� Applicant % RESIDENTIAL APPLIANCES NOT OVER 3 HP NOTIC TOA PLICANT -If, aftg6pWaking At is-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 PERAPPLICAIT NT provisions or this permit shall be deemed revoked Power Apparatus&Large Appliances 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 /A (commencing with Section 7000) of Division 3 of the Business and CITY Tel No Over 10 to 50 Incl Professions Code,and my license is in full force and effect LICENSE ORr/,e� '� ^ } Over 50 to 100 Incl REG NUMBER rj 1 Class a Over 100 DISTRICT NO P SED BY 0 License Number v !lIJJ Lic Class v - Services,Swbd,MCC&Panelboards Qcc Contract o/<<,^1JlC� �(16��i��nte L 0-399 Amp Under 600 V FINAL 0 DATE ❑ 400-1000 Amp Under 600 V �� I am exempt under Sec VALIDATION W Over 1000,Amp or Over 600 V FINAL B&P C for this reason BRANCH CIRCUIT FEES BY a / I 15A,or 20A, 120V,Lighting or Recept Z e' 1 To 10 Branch Circuits Signature -- - 11 To 40 Branch Circwts ❑ r 41 Or More Branch Circuits Exemptiofor eg Maint Elect 15A 20A,208V To 277V Lighting Br Circuits SINGLE FAMILY Temp Power Pole&Appurtenancess x s _ HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit _'I f0 ��?,- `I 1 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 TTi Code) 1 ❑ 'I,as owner of the property,will do tho work and the structure Misc Conduits&Conductors - TOTAL T AL 11 20 is riot intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) 4 hE v 117.2 I and Professions Code) CONSTRUCTION LENDING AGENCY 00L 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) O 0V _ _ Civ C) � '71�;Lil:'.I.tl�l�11�.�2f r-fi PLAN CHECKING FEE i Lender's Name 400 PERMIT ISSUING FEE Lender's Address I certify that I have read this application and under penalty of pur)ury state TOTAL FEE / that the above information is correct I agree to comply with all County ' ordinances and State I s reguI It Electrical wiring,and hereby authorize representatives o t County ter pon the above- entioned property - for inspection2o, ;es SEE REVERSE FOR EXPLANATORY LANGUAGE SIGNA RE PERMITT WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12-91) APPLICATION FOR ELECTRICAL PERMIT I hereby aifiirm that 1 have a certificate of consent to self insure, 76A663 cV 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.) Policy NoW94WQUW Company e&0W FOR APPLICANT TO FILL IN S _ Certified copy is hereby furnished. IF New Residential Bldgs.&Pools NO. EACH FEE ADDRESS ❑ 1 &2-Family,Sq. Ft. _ $ $ Certified copy is filed with the county buildi inspection NEAREST departent. Multi-family Sq.Ft. CROSS ST. Residential Swimming Pools ASSESSOR f� PARCEL D- Date App MAP BOOK a� Q PAGE � OWNER CERTIFICATE OF EXEMPTION FROM WOR ERS' Outlets:Rec._Light Sw. FIRM NAMR COMPENSATION INSURANCE First 20 n,_ n ea (This section need not be completed if the work involved by the ADDRESS permit is for one hundred dollars($100)or less.) %Total No. Additional &t co, certify that in the performance of the work for which this permit CITY el.No611-7 is issued, I shall not employ any person in any manner so as to PLAN 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 suchAPPLICAN provisions or this permit shall be deemed revoked. Power Apparatus&Large Appliances _ LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADORES PLA 1 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 CIT1C1 Tel.No. „ Professions Code,and my license is in full force and effect. Over 10 to 50 Incl. LICENSE OR d Over 50 to 100 Incl. REG.NUMBER S Class.C_� /�JJ Over 100 DISTRICT NO. ESSED BY License Number ! '7'� Lic.Class e�� y Services,Swbd.,MCC&PanelboardsGCr" FINAL Contractor Date 0-399 Amp. Under 600 V DATE V ❑ 400-1000 Amp. Under 600 V I am exempt under Sec. VALIDATION LU Over 1000 Amp.or Over 600 V FINAL d B.&P.C.for this reason BRANCH CIRCUIT FEES BY Z Date: 15A,or 20A, 120V,Lighting or Recept. 1 To 10 Branch Circuits Signature 11 To 40 Branch Circuits El Exemption Or More Branch Circuits ` Exemption for Reg.Maint.Elect. 15A,20A,208V To 277V Lighting Br.Circuits .E T T ENI SINGLE FAMILY Temp.Power Pole&Appurtenances HOME OWNER-BUILDER DECLARATION _t [ = I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit 15 for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits ' Code): _E w 1 ElI,as owner of the property,will do the work and the structure -Misc.Conduits&Conductors = �E is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) , and Professions Code). i c)it 0— 3110 011 r '.' 4 CONSTRUCTION LENDING AGENCY "7,3,x; Z •'•..:�t z='t•_ 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) Civ. C.) PLAN CHECKING FEE Lender's Name ! O PERMIT ISSUING FEE (p Lender's Address I certify that I have read this application and under penalty of purjury state TOTAL FEE f 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 ection pur ose . SEE REVERSE FOR EXPLANATORY LANGUAGE r -7/2-7 SIG E OF PERMI DATE