HomeMy Public PortalAbout5116 DOREEN AVE_Electrical__ COUNTY OF IAS ANGELES TEMPLE CITY p 0508 ELECTRICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS EL 0506 1209260006
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
LEGAL ID: I FEES PAID BUILDING ADDRESS:
IBK: 254 PG: 39 PC: 2 1 5116 DOREEN AV 91780
FEE DESCRIPTION: QUANTITY: GEM: AMOUNT: ( TEMP CA
(ASSESSOR INFORMATION NUMBER I NEAREST CROSS STREET: FREER
18585-022-045 JAI PERMIT ISSUANCE FEE 27.80 THOMAS PAGE: GRID: LOCALITY: TEMPLE CITY, Cl
IG1 OUTLETS-LGT,SW,RECP 10.00 OUT 20.00
1 TENANT: IG2 LIGHTING FIXTURES 8.00 LGT 16.00 JISSUED ON: PROCESSED BY: PLAN BY: 1
HA FAU LESS 3HP 2.00 FAU 22.00 109/26/12 SR
H7 RES EXHAUST FANS 1.00 EX 11.00 1
IOWNER: TEL. NO: JJB AC UNITS r3-10HP 2.00 AC 39.40 1FINAL qI4TE FIBY: CODE: 1
KEY COMMUNITY HOUSING - - TOTAL FEES 136.20 � \ (� �,
15116 DOREEN AV \
TEMP 917803438 1DESCRIPTION OF WORK
I (ELECTRICAL FOR REMODEL 10 OUTLETS, 6 LIGHT FIXTURES, EXHAUST(
I IFAN, A/C AND FAU' I
IAPPLI CANT: TEL. N0:
ISCOTT BROWN DESIGN (323) 256-6336- 1
11444 POPPY PEAK I ISPECIAL CONDITIONS:
(PASADENA CA 91105 J
v5jx CG1-l $�3031�(� I
CONTRACTOR: TEL. NO: JAPPRdkVALS DATE INSPECTOR SIGNATURE
MICHAEL G ROELLE PLUMBING (626) 960-0344- 1
15057 LANTE STREET LIC. NO 1TEMPORARY POWER POLE I
IBALDWIN PARK CA 91706 743562SC16 1_ 1 1
• (UNDERGROUND CONDUIT
ARCHITECT OR ENGINEER: TEL. NO: 1UFER GROUND
HELOU STRUCTURAL ENG (818) 345-7646- - 1
15585 RESEDA BLVD. 105 LIC. NO: 1ROUGH CONDUIT
TARZANA, CA 91356 NONE
IROUGH WIRING
(MAIN.WATER LINE \
PLASTIC YIN METAL YIN
UTILITY COMPANY NOTIFIED
I I I I I I
I I I I I I
I I I I I I
I I I I I
I I I I I I
I I I I I
I` ADDITIONAL DATA ON FILE
REPORT ID: DPR265 ROUTE TO: BS0508
,- WORKER'S COMPENSATION DECLARATION 76A663 DPW(12-91) APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that 4Ta'a a certificate of consent to self insure, - t j
' or a Lertificale of Workers Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV. •'�:.;.
copy hUredP(Sec.3800 Lab. C.)
Policy No. Company FOR APPLICANT TO FILL IN JOB
ADDRESS �// ��G1L�V ��r \�•,•'
NO. EACH FEE
'Certified copy is hereby furnished. New Residential Bldgs.&PoolssLOCALITY
LLM G� C�
Fl Certified &2-Family,Sq.Ft.a�y.SO = $ '0
Certified copy i5 filed with the county building inspection NEAREST
department. Multi-family Sq. FL CROSS ST. �
Date - Applicant Residential Swimming Pools ASSESSOR
MAP BOOK PAGE PARCEL
r CERTIFICATE OF EXEMPTION FROM WORKERS' Oullats'Rec.—Light SOWNER OR
COMPENSATION INSURANCE g w. ITR.M NAME 7-FC-6-
�( Lzv6- 4%.1a
(This section need not be completed if the work involved by the Total No. Aldditional ADDDRESS r�/¢
permit is for one hundred dollars($160)or less.)
I certify that in the performance of the work for which this permit CITY is
TeI.No✓ -�
is Issued, I Shall net employ any person in any manner 50 a5 to PLAN CRECK �.(
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. o f�
provisions of the Labor Code, you must forthwith comply with such APPLIICANT
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 101nd.
(commencing with Section 7000) of Division 3 of the Business and CITY T.I.No.
and m license is in full force and effect. Over 10 to 50 Incl. LICENSE OR j.
Professions Coda, y Over 50 to 100 Ind. REG. SE OR Class. 4.
Over 100 DISTRICT NO. PRO ED BY O
License Number Lia Class r V
Services,Swbd.,MCC&Panaboards �.7 '0� L� �
Contractor Date 0-399 Amp. Under 600 V FINAL
DATE l
❑ am exempt under Sea 400-1000 Amp.Under 600 V - -g VALIDATION W
Over 1000 Amp.or Over 600 V FINAL
--- B.&P.C.for this reason - BRANCH CIRCUIT FEES BY .. (n
Date: 15A,or 20A, 120V, Lighting or Recept. Z
1 To 10 Branch Circuits. '
Signature 11 To 40 Branch Circuits -
F-1
i 41 Or More Branch Circuits -"-- '
'Exemption for Reg.Maint.Elect. 15A,20A,208V To 277V Lighting Br.Circuits ACCT.A
Y
SINGLE FAMILY Temp. Power Pole&Appurtenances 3307 290.25
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit - ' - --- - -
ITEMS-
hereby affirm that I am exempt from the Contractor's License Law 1 I�'EI M i�
for the following reason (Section 7031 5, Business and Professions Additional Sign Branch Circuits -
Cede): TOTAL 290 - 25
❑ v
Misc.Conduits&Conductors "' -� --'"" "-'" ' ' ��-
I, as owner of the property,will do the work and structure _tic I` ^n �
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) f'n'gCrCS +_l'J �`t
and Professions Code). ® CHANGE e CONSTRUCTION LENDING LENDING AGENCY l { '
I hereby affirm that there is a construction lending agency for the 11QI)�-I��I]1 1.�.}i
performance of the work for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total) �3 - 1!•� C/Q7
Civ. C.) �l�v i AIM:1d
PLAN CHECKING FEE _
Lender's Name
Lender's s
PERMIT ISSUING FEE
I certify that at I have read this application and under penalty of perjury stale 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 purjaades. SEE REVERSE FOR EXPLANATORY LANGUAGE
r
/-2z 13
SIGNATURE OF PERMITTEE DATE