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WOrm th COMPENSATION DECLARATION - 10/81 APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I hgve a certificate of consent to self
Insure, or a certificate ofWorkers'Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified copy thereof (Sec. 3800, Lab. C.)
Policy No. Company FOR APPLICANT TO FILL IN ADDRESS �
Certified copy Is hereby furnished. New Residential Bldgs. 8 Pools EACH NO. FEE
S — S
El Certified copy Is filed with the county building Inapec- 1 8 2-Family, Sq. Ft. LOCALITYNEARESTIlan department. Multl-famlly Sq. Ft. — CROSSDate Applicant Residential Swimming Pools 0w44ER OR
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Llght Sw. MAIL
COMPENSATION INSURANCE ADDRESS
Flrft 20
(This section need not be completed H the work Involved by Total No Additional CffY T.I. IN
the pormM Is for one hundred dollars (=100)or less.) PLAN CHECK
1 certify that In the performance of the work for which this
permit Is Issued, I shall not employ any person In any manner
so as to become subject to the Workers Compensation Laws. Lighting Fixtures First 20 ADDRESS
A Total No. Additional
CITY Tel. No.
Dat Ilcant Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLI ft
: If, aer making hls Certificate of ��N7
Exemption, you should become subject to the Workers' Range_ Heater_D.W. _
Compensation provlslons of the Labor Code, you must forth- Oven _ Dryer — W.M.— ADDRESS
with comply with such provisions or this permit shall be Top _ FAU —W.H. —
deemed revoked. Hood _ Fan _ Other_ CITY Tel. tJo.
LICENSED CONTRACTORS DECLARATION DI _ Room Alr Cond. LKBJSE
hereby affirm that I am Ilcerued under provisions of Chapter 9 sp' Rf G. N Class.
(commencing with Section 7000) of Division 3 of the Business Power Apparatus 8 Large Appliances DISTRICT NO. PROCE
and Professions Code,and my license is In full force and effect.
Size 8 Type HP, KW, KVA, or KVAR 5a -
License Number Llc. Class 7
Up to 1 Incl. FINAL
Contractor Data Over 1 to 10 Incl. Ds��/Z VALJ yypM C7
Over 10 to 50 Incl. FI
I am exempt under Sec. Over 50 to 100 Irrc. B
B.BP.C. for this reason Over 100 Z
Services, Swbd., MCC 8 Panelboards
Date: 0 -200 Amp. Under 600 V
Signature 201 - 1000 Amp. Under 600 V
❑ Exemption for Reg. Malnt. Elect. Over 1000 Amp. or Over 600 V
SINGLE FAMILY Temp. Power Pole 8 Appurtenances # 6 9 o
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License Additional Sign Branch Circuits .1 o - 2550
Law for the following reason (Section 7031.5, Buslneu and
Profenlons Code): - 2a506
0
I, as owner of the property, will do the work and the Mlsc. Conduits 8 Conductors
�
structure Is not Intended or offered for saie (Section Other (See Complete Fee Schedule)_ 5 2 3 8 6'
7044, Business 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 PERMIT FEE (Sub-Total)
(Sec. 3097, Civ. C.).
PLAN CHECKING FEE
Lenders Name
PERMIT ISSUING FEE
Lender's Addreu
I certify that I have read this application and state that the TOTAL FEE
above Information Is correct. I agree to comply with all County
ordinances and State lawn regulating Electrical wiring, and
hereby authorize representatives of this County to enter upon
e above-mentioned property for Inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of PUmIttao Data
1
• COIINL7 O
_. F LOS ANKIELF4 TEMPLE CITY 9 0508 EL = PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS T[2W RL 0508 0711140003
BUILDING AND SAkj= / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
LEGAL ID: FRMS PAID BUILDING ADDRESS:
TR: 5904 LT: 190 9049 GAR-lBALd)I AV
FEE DES(PTPTION: QUANTITY: DOM: AMOUNT: TEMP CA 917801620
ASSESSOR INFORMATION NUMBER: NTAPTST CROSS STT-=: SULTANA
5384-008-002 A-1 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 596 GRA: H2 LOCALSTY: TEMPLE CZ'L'Y, C
F1 12OV, 15/20A BR CKTS 7.00 BR 120.75
TE Urr: G2 L.IGHT NG FIXTURES 24.00 LO05/12/0
T 44.40 ISSUED ON: PROCESSED BY: PLAN BY: 05/12/08
EMPIRES ON:
H2 RFS GRBG DISP LT 3HP 1.00 DIS 10.95 11/14/07 SR
H3 RES DLSHWA.SHR LT 3HP 1.00 DI8 10.95
OWNER: TEL. NO: H4 RES RANGE HD8 LT 3HP 1.00 HOO 10.95 F12ZAL DATE FINAL BY: CODE:
LEE, mis (626) 236-3091- HS RES WASH MACH LT 3HP 1.00 WAS 10.95
9049 GARIBALDI AV H7 RES RKHADST FANS 1.00 EK 10.95
TFN:P 917801620 LB 200 AMP PANS, MCC 1.00 PAN 38.85 DESCRIPTION OF WORK
TOTAL FEES 286.50 FI&CTRICAL FOR INTERIOR R-EWDEL AND UPGRADE SERVICE PANKL
TO 200 AMP
APPLICANT: TEL. NO:
TAN (626) 318-7973-
2238 C3?�'[3WDOD ST.
SPECIAL CO®TTIO�i9:
LOS ANGEJM CA 90031
CONTRACTOR: TEL. NO: APPROVALS DATE INSPECTOR SIGNATURE
Sapp TAN (626) 318-7973-
. 2238 GATE1100D STREET LIC. NO TFJ�(ntARY POWER POLE
LOS ANGELES, CA 90031 782397 B
UNDERGROUND CONDUIT
ARCHI'= OR RNGIN]M: TEL. NO: LIFER GROUND - - -
LIC. NO: ROUGH{ CONDUIT .
ROUGH WIRING
MAIN WATER LINE
PLASTIC YIN METAL YIN -
UTILITY COMPANY NOTIF r
REPORT ID: DPR265 ROUTE! TO: B30508