HomeMy Public PortalAbout5829 ROSEMEAD BLVD_Electrical__ r `• WORKERS'COMPENSATION DECLARATION 7MM3 DPw3/87 APPLICATION FOR ELECTRICAL PERMIT O
(.J9ereby affirm that I have a certificate of consent to self ce-so c
insue, or a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
or q csrrtiPied copy thereof (Sec. 3800, Lab. C.)
Policy0slo. Company FOR APPLICANT TO FILL IN JOB -
Certified copy is hereby furnished. New Residential Bldgs. 8 Pools EACH NO. FEE ADDRESS �- C U 5.A4/`�
X�Certified co is filed with the count building pec- 1 &2-Family, S Ft. $ -- $ LOCALITY TN �£ �'� T
PY � Y 9 ins Y. 9•
tion deportment. r Multi-family Sq. Ft. NEAREST -11M0
., / J Residential SwimmingPools CROSS ST. !�f�t�G S
Date 3 Applicant --��` r -`t OWNER OR
� FIRM NAME �t 4F _/f-CT i ���
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec i`3 Light CF �Sw.7�� . ^G Q� AMAIL
DDRESS G F_ FCT�i�� �l�tY
COMPENSATION INSURANCE First 20 d1
(This section need not be completed if the work involved by Total No. Additional ! Aja CITY L4 1/1-7^n/,f= Tel. No.)/-/ j-r ; )�
the permit Is for one hundred dollars($100)or less.) PLAN CHECK
1 certify that in the performance of the work for which this I APPLICANT
permit is issued, I shall not employ any person in any manner Lighting Fixtures First 20 ADDRESS
so as to become subject to the Workers'Compensat' ws. g g
Additional
Date /-3i-9/ Applicant 'z`�' '1.�.� Total No. CITY Tel. No.
NOTICE TO APPLICANT: If, after makingthis Certificate of Fixed Appliances Not Over 1 HP PERMIT
Range— Heater—D.W. — APPLICATION
Exemption, you should become subject to the Workers'
Compensation provisions 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. No.
LICENSED CONTRACTORS DECLARATION LICENSE OR
Disp. _ Room Air Cond. — REG. NUMBER Class.
I hereby affirm that i am licensed under provisions of Chapter 9
(commencing with Section 7000)of Division 3 of the Business Power Apparatus&Large Appliances I DISTRICT NO. PROCESSED BY a
�n and Prof ssions Code,and m license is in full force and effect. ,L�
O7' ID�31 ���( y 1 Size&Type HP, KW, KVA, or KVAR 5, - O
Lic nse umber g� .3`�7 Lic. Class CSC FINAL _ V
Up to 1 Incl. DATE �j cc
//�� +ArC _ Over 1 to 10 Incl. L VALIDATION O
Contractor / if/A/��1F �k is Date - 3� % Over 10 to 50 Incl. U
❑ FINAL
I am exempt under Sec. Over 50 to 100 Inc. I BY W
B.&P.C. for this reason Over 100 d
Services, Swbd., MCC&Panelboards , A' • es Z
_ Z
Date: 0-200 Amp. Under 600 V _Ljr? :1
Signature 201 - 1000 Amp. Under 600 V
Over 1000 Amp. or Over 600 V
Exemption for Reg. Maint. Elect. 70TAL 322 00
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 Additional Sign Branch Circuits
Professions Code):
I, as owner of the property, will do the work and t Misc. Conduits&Conductors
e - �'-
structure is not intended or offered for sale(Section 7044, her sSee Com�plete Fee S hedule)_
Business and Professions Code). -y� "oov, m;T -/di �� Fnc� _ d D ® =77
CONSTRUCTION LENDING AGENCY -`y '"r 4 3D
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) 0
(Sec. 3097, Civ. C.).
PLAN CHECKING FEE
Lender's Name PERMIT ISSUING FEE LL.�
Lender's Address TOTAL FEE
I certify that I have read this application and state that the -3,1A Ly
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 upop '
the above-m Miopperty for inspection purposes.�/. SEE REVERSE FOR EXPLANATORY LANGUAGE
-31
Signature of Permittee Date I
P i
' WOR :I have cerci DECLARATION I 20.0019 DPW 3/87 APPLI( 1' ON FOR ELECTRICAL PERMIT O
�hcreby affirr I have a certificate of consent to self I .�
,.inspire, or a ce _.e of Workers'Compensation Insurance, I COUNTY OI -. j ANGELES I DEPT. OF PUBLIC WORKS
orkertified copy thereoff7(S(e�c.�3')800, Lab. C.)
Policy NoLL_ QoiripMiyIJ FOR APPLICANT TO FILL IN JOB
❑Certified copy is hereby furnished. New Residential Bldgs. &Pools EACH NO. FEE ADDRESS66261 ,
ertified copy is filed with the county building inspec- 1 &2-Family, Sq. Ft. $ — $ LOCALITY -�/
Joon department. Multi-family Sq. Ft. — I NEAREST
// �? Residential Swimming Pools CROSS ST.
Date /Z�f --"1 Applicar) Ici g I FIRMNER OR
NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw.— MAIL
COMPENSATION INSURANCE ADDRESS
First 20
(This section need not be completed if the work involved by ( � CITY
the permit is for one hundred dollars($100)or less.) Total No. Additional
PLAN CHECK
I certify that in the performance of the work for which this i APPLICANT
permit is issued, I shall not employ any person in any manner i Lighting Fixtures First 20 I ADDRESS
so as to become subject to the Workers'Compensation Laws. g g
Additional j
Total No. CITY Tel. No.
Date Applicant Fixed Appliances Not Over 1 HP I PERMIT
NOTICE TO APPLICANT: If, after making this Certificate of APPLICATION
Exemption, you should become subject to the Workers' Range— Heater—D.W. —
Compensation provisions of the Labor Code, you must forth- I Oven — Dryer —W.M.— i ADDRESS I
with comply with such provisions or this per shall be Top — FAU —W.H. —
deemed revoked. I CITY I Tel. No. (a
I Hood — Fan —Other— �
LICENSED CONTRACTORS DECLARATION ' LICENSE OR
I.hereby affirm that I am licensed under provisions of Chapter 9 Disp. _ Room Air Cond. _ REG. NUMBER I�� 3 Class.
(commencing with Section 7000)of Division 3 of the Business Power Apparatus&Large Appliances DISTRICT NO. PROCESSED BY >_
and Professions Code,and my license is in full force and effect. Il
�� /� Size&Type HP, KW, KVA, or KVAR , 0
License Number Cal(�6TCJ� Lic. Class Up to 1 Incl. f FINAL V
Contractoate // , Over 1 to 10 Incl. j DATE �
r(_ Z—G�1I VALIDATION O
Over 10 to 50 Incl. F–
I am exempt under Sec. i Over 50 to 100 Inc. I BY
❑
B.&P.C. for this reason Over 100 `1 a
®
Services, Swbd., MCC&PanZ
elboards
Date: 0-200 Amp. Under 600 V Z—
Signature 201 - 1000 Amp. Under 600 V
❑ Over 1000 Amp. or Over 600 V
Exemption for Reg. Maint. Elect. I I
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Temp. Power Pole&Appurtenances r'
I hereby affirm that I am exempt from the Contractdr's License I Sign with One Branch Circuit I 4
b Branch Circuits n y� I
Law for the following reason (Section 7031.5, Business and
ns I Additional Sign i _7�f �� `
ProfessioCode): i !
-bL!�•
❑ I, as owner of the property, will do the work and the Misc. Conduits&Conductors i i
structure is not intended or offered for sale(Section 7044, Other(See Complete Fee Schedule)_
Business and Professions Code). ® I lr:l;� 3 ® DO
CONSTRUCTION LENDING AGENCY i i�%f-i:
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) I JNa<i;i'��
(Sec. 3097, Civ. C.).
PLAN CHECKING FEE I
Lender's Name
PERMIT ISSUING FEE
Lender's Address J•_�G I �1i"I Llny
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 I
ordinances and State laws regulating Electrical wiring, and
hereby authorize representatives of this County to enter upon
the bove;mentioned pr perty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
� I
/-"RI-'R'i
Signature of Permittee Date ®'
i
WORKERS'COMPENSATION DECLARATION , 20.0019 DPW 3/87 O
hereby affirm that I have a certificate of consent to self ' 7E APPLICATION FOR ELECTRICAL PERMIT
insure, or a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
or a certified 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 EACH NO. FEE
_ $ l
Certified copy is filed with the county building inspec- 1 &2-Family, Sq. Ft. $ LOCALIT_ I NEAREST
tion department. Multi-family Sq. Ft.
Residential Swimming Pools OW RST.OR
Date Applicant FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw._ MAIL
COMPENSATION INSURANCE ADDRESS
(This section need not be completed if the work involved by First 20 CIT Te. No.
the permit is for one hundred dollars(;100)or less.) Total No. Additional S
PLAN CH CK
1 certify that in the performance of the work for which this APPLICANT
permit is issued, I shall not employ any person in any manner Lighting Fixtures First 20 ADDRESS
so as to become subject to the Workers'Compensation Laws.
' 1 ` _— Additional
Date Applican�►1 UY 7�`� Q t� Total No. CITY Tel. No.
NOTICE TO APPLI 'ANT: If, after makin this Certificate of Fixed Appliances Not Over 1 HP PERMIT
Exemption, you should become subject to the Workers' Range— Heater—D.W. — APPLICATION
Compensation provisions 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. No. -� 110
LICENSED CONTRACTORS DECLARATION I LICENSE OR
Disp. _ Room Air Cond. — Class.
I hereby affirm that I am licensed under provisions of Chapter 9 REG. NUMBER
(commencing with Section 7000)of Division 3 of the BusinessI Power Apparatus&Large Appliances DISTRICT NO. PROCESSED BY d
and Professions Code,and my license is in full force and effect.
I Size&Type HP, KW, KVA, or KVAR ,ff� O
License Number T,Ut421 Lic. Class_ Up to 1 Incl. FINAL
DATE
E e_c9l` `A_`\_QL� Over 1 to 10 Incl. 4�` VALIDATION 0
Contract^� Date \�— Over 10 to 50 Incl. U
❑ FINAL
I am exempt under Sec. Over 50 to 100 Inc. BY LIJ
B.&P.C. for this reason Over 100 (..
Services, Swbd., MCC&Panelboards U)
n^�. Z
1�jIJQ- i 0-200 Amp. Under 600 V
Signature ■ � 201 - 1000 Amp. Under 600 V
❑ Over 1000 Amp. or Over 600 V
Exemption for Reg. Maint. Elect.
SINGLE FAMILY Temp. Power Pole&Appurtenances i; s. s
HOME OWNER-BUILDER DECLARATIONvsvt ,4
Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License r� •-r
Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits __I o:-�
Professions Code): I .l
IiEr_
❑ I, as owner of the property, will do the work and the Misc. Conduits&Conductors i L
Q —, -
Other See Complete Fee Schedule
structure is not intended or offered for sale(Section 7044, ( P )—
i lL a
Business and Professions Code). CHECK
CONSTRUCTION LENDING AGENCY .I i
I hereby affirm that there is a construction lending agency for CHANGE
the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) /
(Sec. 3097, Civ. C.).
PLAN CHECKING FEE Y 619i
Lender's Name / c ?�
PERMIT ISSUING FEE !O � =�� 1 AN
Lender's Address
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 laws regulating Electrical wiring, and
hereby authorize representatives of this County to enter upon
the ab e-mgntioned property r inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date
V RS'COMPENSATION DECLARATION �?.0�Wa1�9DPVV3/87 APP ATION FOR ELECTRICAL PERMIT
y� I '�er�by c that I have a certificate of consent to self cE•BpyD
it aur , ore. ,_.ficate of Workers'Compensation Insurance, i COUNTY VF LOS ANGELES DEPT. OF PUB IC WORKS
or a•,sertified copy thereoflaSec. 3800, Lab.
Policy NofaCBompany +lt4l FOR APPLICANT TO FILL IN JOB
❑Certified copy is hereby furnished. „(,C, Gs..h Y New Residential Bldgs. &Pools EACH NO. FEE ADDRESS �ROSq asPr'1 PQ
rtified copy is filed with the county buildin ins c- 1 &2-Family, Sq. Ft. $ — $ LOCALITY70—yy, Je f
NEAREST ������ `� �
tion de art n. Multi-family Sq. Ft. CROSS ST. (T(�l�+�� S
s �7 Residential Swimming Pools OWNER OR /, / -�
ck
Date Applicant lk U'
IF FIRM NAME ti
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw._ MAIL COMPENSATION p /Jr "n 61 �1/�,
COMPENSATION INSURANCE First 20 ADDRESS
(This section need not be completed if the work involved by CITY A. S-` 11103Tel. No. �"&-7G9
the permit Is for one hundred dollars($100)or less.) Total No. Additional
PLAN CHEKM T
I certify that in the performance of the work for which this I APPLICANTT /YL//Iq– ILh s r1 C .
permit is issued, I shall not employ any person in any manner Li htin Fixtures First 20 ADDRESS '
so as to become subject to the Workers'Compensation Laws. g g �,C1 r /3, �T V 6
I. Additional
Total No. CITY �Ck-It NO$Tel. 20? `D Yl-2821
Date Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, after making this Certificate of I G Range— Heater—D.W. — APPLICATION 1�(
Exemption, you should become subject to the Workers' I 9
Compensation provisions 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. I Hood — Fan —Other— CJITY 5_J5Ck7-r->\ Tel, 951-2*2)
LICENSED CONTRACTORS DECLARATIONLICENSE OR s�p
I Disp. _ Room Air Cond. — a /Tj 7.5-6 Class.4x�
I hereby affirm that I am licensed under provisions of Chapter 9 I REG.NUMBER
(commencing with Section 7000)of Division 3 of the Business ower Apparatus&Large Appliances DISTRICT NO. P O SSED BY a
and Professions Code,and my license is in full force and effect. y y
Z � t Size&Type HP, KW, KVA, or KVAR . p p O
License Number v^ Li . Class a/� Up to 1 Incl. FINAL V
/7 Over 1 to 10 Incl. DATE VALIDATION IO
Contractor Over 10 to 50 Incl. '� H
❑ I am exempt under Sec. ' Over 50 to 100 Inc. BY
4A w
B.&P.C. for this reason I Over 100 IL
® to
Services, Swbd.,.MCC&Panelboards Z
Date: 0-200 Amp. Under 600 V —
Signature i 201 - 1000 Amp. Under 600 V
❑ Exemption for Reg. Maint. Elect. Over 1000 Amp.. or Over 600 V
SINGLE FAMILY Temp. Power Pole 8 Appurtenances
HOME OWNER-BUILDER DECLARATION o a
I hereby affirm that I am exempt from the Contractor's License Sign with One Branch Circuit
Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits ±Ali I,
�z
Professions Code):
Misc. Conduits&Conductors ' 11E .
❑ I, as owner of the property, will do the work and the � -- —a
structure is not intended or offered for sale(Section 7044, Other(See Complete Fee Scheduled �.1)7AL. ,s7 ® 00
Business and Professions Code). I ® -NECK 37 rr-
CONSTRUCTION LENDING AGENCY __
I hereby affirm that there is a construction lending agency for `:e'�r'�_NG3E o 111:
the performance of the work for which this permit is issued PERMIT FEE (Sub-Total)
(Sec. 3097, Civ. C.).
PLAN CHECKING FEE LI:ICI_I:I iris :a 4
Lender's Name PERMIT ISSUING FEE � ?,�i jl i � A� *:q 1;•_
Lender's Address
I certify that I have read this application and state that the C
TOTAL FEE q 7. &'p
above information is correct. I agree to comply with all County
ordinances and State laws regulating Electrical wiring, and
hereby authorize
represent t* es of this County to enter upon
the above-authorize
ori this ion p poses.
` SEE REVERSE FOR EXPLANATORY LANGUAGE
�/� vSign tura of rmimie Date ®`
V RS'COMPENSATION DECLARATION 120 DPW 3/87 O
thereby c that I have a certificate of consent to self CE-806GAPPI ,ATION FOR ELECTRICAL PERMIT
insure, or. _ ficate of Workers'Compensation Insurance, COUNTN vr•L'OS ANGELES DEPT. OF PUBLIC WORKS
or a c%tified cil y thereof(Sec. 3 Lab. C. ,.�//�
Polic No r ompan `�^�w`v"`� FOR APPLICANT TO FILL IN JOB �p�
1/Certified copy is hereby furnished. New Residential Bldgs. &Pools EACH NO. FEE ADDRESS O
❑Certified co is filed with the count building $ — $ LOCALITY
copy y g inspec- 1 &2-Family, Sq. Ft.
tion epa tment. Multi-family Sq. Ft. — NEAREST
3Residential Swimming Pools CROSS ST.
Date A licant OR
Pp FIRM NAME L .
CERTIFICATE OF EXEMPTI ROM WORKERS' Outlets: Rec Light Sw.— MAIL
COMPENSATION INSURANCE First 20 ADDRESS
(This section need not be completed if the work Involved by CITY Tel. No.
the permit,is for one hundred dollars($100)or less.) Total No. Additional t UC)
PLAN CHECK
I certify that in the performance of the work for which this APPLICANT
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.
Date Applicant Fixed Appliances Not Over 1 HP PE MIT ,�
NOTICE TO APPLICANT: If, after making this Certificate of PLICATION / ,
Exemption, you should become subject to the Workers' Range— Heater—D.W. —
Compensation provisions 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 �/ U4
Tel. No v3S Q
LICENSED CONTRACTORS DECLARATION LICENS OR 17
Disp. — Room Air Cond. — 7 Class.r//
REG
I hereby affirm that I am Licensed under provisions of Chapter 9 . NUMBER
(commencing with Section 7000)of Division 3 of the Business Power Apparatus&Large Appliances DISTRICT NO. PR CESSED BY a
and Professions Code,and my license is in full force and elle .
Cie
�, Size&Type HP, KW, KVA, or KVAR U
License Number �'/�j Lic. Class Up to 1 Incl. FINAL
1-1
C-1 ?� I Over 1 to 10 Incl. DATE t( _ Z ` VALIDATION cc
Cantracto Date Over 10 to 50 Incl. U
❑ FINAL
I am exempt under Sec. Over 50 to 100 Inc. BY 9 �- �� W
B.&P.C. for this reason Over 100 'J a
Services, Swbd., MCC&Panelboards , Z
Date: Z
l 0-200 Amp. Under 600 V
Signature 201 - 1000 Amp. Under 600 V
❑ Exemption for Reg. Maint. Elect. Over 1000 Amp. or Over 600 V i
SINGLE FAMILY Temp. Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION
Sign with One Branch Circuit t.
I hereby affirm that I am exempt from the Contractor's License i H.•t•:.a
Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits
Professions Code): ,:
I, as owner of the property, will do the work and the Misc. Conduits&Conductors ! 14 01
❑ 1
structure is not intended or offered for sale(Section 7044, Other(See Complete Fee Schedule)— , yt-ITAL 33-00
Business and Professions Code). r
CONSTRUCTION LENDING AGENCY I CHECK
I herebyaffirm that there is a construction lendingagency for
the perormance of the work for which this perit is issued PERMIT FEE (Sub-Total)
(Sec. 3097, Civ. C.).
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE �
Y! 4
Lender's Address y� 6041E 1 AN 1111?
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 laws regulating Electrical wiring, and I'
hereby authorize representatives of this County to enter upon
the above-mentio d property for inspection yuurrpCses. SEE REVERSE FOR EXPLANATORY LANGUAGE
Sig atu of PermitteeDate ®s
1
WORKER'S COMPENSATION DECLARATION 76AAB°B'a DPW(t2-9t:) 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 I 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
ADDR t7( S�r/ J6�
Certified copy is hereby furnished. New Residential Bldgs.&'Pools NO. EACH FEE' '. ��
_' $ $ LOCALITY Zj/� C_C.— �D l
❑ Certified copy is filed with the county building inspection 1&2-Family,Sq.Ft.
department. Multi-family Sq.Ft. CROSS SST. e Q
Date Applicant Residential Swimming Pools ASSESSOR
MAP BOOK I PAGIE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec.—Light Sw. OWNER G -/
COMPENSATION_INSURANCE First 20 FIRM NAME.. Q 6•s ®w!�?
(This section.need not be completed If the work Involved by the pooR �y,,,/t! ` �r 7
permit is for.one hundred dollars($700)or less.) Total No. Additional 492
I certify that in the performance of the work for which this permit OrAimece, Q, (,;�
Is issued, I shall not employ any person in any manner so as to PLAN CHECK
become subject to the Workers'C ensation Laws. Lighting Fixtures First 20 APPLICANT
Total No. Additional
F C ADDRESS
Date pplic.. RESIDENTIAL APPLIANCES NOT OVER 3 HP.
NOTICE TO'APPLICANT: If, after making this Certificate of CITY Tel.No.
Exemption,you should become subject to.the Workers'Compensation, OTHER APPLIANCES NOT OVER 3 HP. /,-
provisions of the Labor Code,you must forthwith comply with such power Apparatus&Large Appliances APw� C:L t5e��lCi
provisions or this permit shall be deemed revoked.
LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDr91/;Z3 �, / Ile—
hereby affirm that I am. licensed under provisions of Chapter 9 Over 3 to 10 Incl. �—{
(commencing with Section 7000)of Division 3 of the Business and CITY ,�� [� r ..
Professions Code,and my license is in full force and effect. Over 10 to 50 Incl.
LICENSE OR —f/' {D >_Over 50 to 100 Incl. REG.NUMBER `{p c a
Over 100 DISTRICT NO. S$ED BY V
License.Number. � Lic.Class I,
Services,Swbd.,MCC&Panelboards ' Uo
66--t---Q -F� Q
Contracto Date 0-398 Amp.Under 600 V DATE
I am exempt under Sec.. 400-1000 Amp.Under 600 V .�
VALIDATION V•
Over 1000 Amp.or Over 600 V FINAL 7OW.
B.&P.C.for this reasonBRANCH CIRCUIT FEES BY (n
ate: 15A,or 20A,120V,Lighting or Recept. Z_
1 To 10 Branch Circuits
Signal e. 11 To 40 Branch Circuits
El
41 Or More Branch Circuits
Exemption for Reg.Maint.Elect. 1,%WA,208V To 277V.U hdng.Br..Circuits
SINGLE FAMILY Temp.Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION AGGT.V
I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit
for the following reason (Section.7031.5, Business and Professions Additional Sign Branch Circuits 33503 48.60
Code): •
❑ Misc.Conduits&Conductors 1 ITEMS
I,as owner of the property,will do.the work and the structure
is not intended or offered for sale(Section 7044, Business Other(See Complete Fee Schedule) TOTAL 48 m 60
and Professions Code).
GHEGw. 48.60 -
CONSTRUCTION LENDING AGENCY CHANGE a 00
I hereby affirm that there is a construction lending agency for the
performance of the work for which this permit is issued (Sec. 309T PERMIT FEE (Sub-Total) r
Civ.C.) I
PLAN CHECKING FEE 0000-0001 6l 3/96
Lender's Name Q 6719 1 AM 9:25
PERMIT ISSUING FEE •
Lender's Address TOTAL FEE Q
I certify that I have read this application and under penalty of purjury state
that.the above Information is correct. I agree to comply with all County
ordinances and State laws regulating Electrical,wiring,and hereby authorize
rep ntatives of this County to enter upon the above-mentioned property.
f pe 2Z&
CAIWEE90
rSEE REVERSE FOR EXPLANATORY LANGUAGE
r
DATE
WORKER'S COMPENSATION DECLARATION 7SA663 9 DPW c12-91, APPLICATION FOR ELECTRICAL PERMIT
78A68
I hereby affirm that I have a certificate of consent to self insure, 'r , , -y
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.)
PJOB
olicy No. Company FOR APPLICANT TO FILL IN ADDRESS 2 \ OSe-
Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE
$ $ LOCALITY
❑ Certified copy is filed with the county building inspection 1&2-Family,Sq.Ft. NEAREST
department. Multi-family Sq.Ft. — CROSS ST. 0.—
Date Applicant Residential Swimming Pools ASSESSOR
MAP BOOK I PAGE PARCEL
1k IL
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec.—Light FIRM N
Sw. OR'"�
COMPENSATION INSURANCE FIRM NAME ,C,
First 20 MAIL �J�
(This section need not be completed the work Involved by the Total No. Additional ADDRESS o
permit is for one hundred dollars(57000)or less.)
I certify that in the performance of the work for which this permit CITYTel.No. 77
is issued, I shall not employ any person in any manner so as to PLAN CHE
become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 APPLICANT
� ( _tC Total No. Additional ADDRESS
Date Applicant VVV a�11[1' RESIDENTIAL APPLIANCES NOT OVER 3 HP
NOTICE TO APPLICANT: If, after making this Certificate off . 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 PERMIT
APPLICANT
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 ! 6
(commencing with Section 7000) of Division 3 of the Business and Over 3 to 10 Incl. CITY `� ` Tel.No
Professions Code,and my license is in full force and effect.. Over 10 to 50 Incl. >.I LICENSE OR Clsss. C
Over 50 t0 100 Incl. REG.NUMBER d
License Number `i_7VUt Lic.Class Over 100 DISTRICT NO. P SSED BY V
pp Services,Swbd.,MCC&Panelboards
Contractor `Bate 0-399 Amp.Under 600 V DATE
400-1000 Amp.Under 600 V O
❑ I am exempt under Sec. �—( [ VALIDATION V
Over 1000 Amp.or Over 600 V FINAL d
B.&P.C.for this reason BRANCH CIRCUIT FEES By
(n
15A,or 20A,120V,Lighting or Recept. 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 z
!' 'j•t
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits -i •,.•. as VC
Code): '_��: e aj
❑ 7slL
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•'•EM6 =
#t �1� ��i.�LI
I hereby affirm that there is a construction lending agency for the / X10
performance of the work for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total) (��
Civ.C.)
PLAN CHECKING FEE
Lender's Name t�fo 1-11, 5/1095
PERMIT ISSUING FEE I A OU 35 1 AN 9:33
Lender's Address
I certify that I have read this application and under penalty of purjury state TOTAL FEE /• oul
that the above information is correct. I agree to comply with all County
ordinances and State laws regulating Electrical wiring,and"! y-authorize
representatives of tkis Cou tyto ent�r y entioned property
flQinsp cti [�on s. SEE REVERSE FOR EXPLANATORY LANGUAGE
` -- �
SIG MI DATE
-04P COUNTY OF LOS ANGELES TEMPLE CITY # 0508 ELECTRICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9071 LAS TUNAS EL 0508 9612040030
♦ BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA
PHONE: (818) 285-0488 EXT:
LEGAL FEES PAID BUILDING ADDRESS:
TR: 3623 LT: 105 5829 ROSEMEAD BL
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917801832
ASSESSOR INFORMATION NEAREST CROSS STREET:
5387-012-018 Al PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 596 GRID: H3 LOCALITY: TEMPLE CITY
E1 TEMP SERV POWER POLE 1.00 TMP 43.50
TENANT: E2 TEMP DIST SYSTEM 1.00 TMP 21.60 ISSUED ON: PROCESSED : PLAN BY: EXPIRES 0 :
TOTAL FEES 92.85 12/04/96 TC 12/04/97
OWNER: TEL. NO: FINAL DATE FINAL B CODE:
333
BANK
HOPE
ASTRICA
LOSA 900711406 DESCRIPTION OF WORK
TEMP. POWER POLE AND LIGHTING F R CHRISTMAS TREE LOT
i
APPLICANT: TEL. O:
JESSE STONE ELECTRICAL (818) 446-3517-
����E qSc, SPECIAL CONDITIONS:
CONTRACTOR: TEL. NO: � t � APPROVALS DATE INSPECTOR SIGNATURE
JESSE STONE ELECTRICAL (818) 446-3517-
2818 FAIRGREEN AVE. LIC. NO �•� oPO POWER POLE
ARCADIA CA 91006 176063 C10
UNDERGROUND CONDUIT
i
ARCHITECT OR ENGINEER:' T 0: -N0: FER GROUND
r = -- -, - ---=` �`
- II11'I ROUGH CONDUIT
LIC.
ROUGH WIRING q
y tir�;4 �'i ,', �, �� II MAIN WATER LINE
PLASTIC Y/N METAL Y/N
UTILITY COMPANY NOTIFIED
rl
I
1
REPORT ID: DPR265 ROUTE TO: BS0508
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 IR.LCAL-ERM• T
DEPARTMENT OF PUBLIC WORKS 9071 LAS TUNAS EL 0508 9803120017
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA
PHONE: (818) 285-0488 EXT:
EGA D: FEES PAID BUILDING DDRE S•
TR: 3623 LT: 105 �5829'R�MEAD BL
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: �i"EMP-CA 9178018
ASSESSOR INFORMATION MB R: NEAREST CROSS STREET:
5387-012-018 Al PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 596 GRID: H3 LOCALITY: TEMPLE CITY
K1 SIGNS, OUTLINE LGT 2.00 SIG 77.70
TENANT: TOTAL FEES 105.45 ISSUED 0 : PROCESSED B : PLAN EXP R S 0
PEPE'S RESTAURANT 03/12/98 UT 03/12/99
OWNER: TEL. NO: FINAL DATE FINAL BY: ODE:
RUSSI, JOSEPH;MARIA 000
5829 ROSEMEAD BLVD. (!
TEMPLE CITY, CA D. SCR_PTION OF WORK
3`u SIGNS S'I�A�RAI�T j
APPLICANT: TEL.
COAST SIGN, INC. (714) 529-9144-
1345 S. ALLEC SPECIAL CONDITIONS:
ANAHEIM, CA
CONTRACTOR: TEL. NO: APPROVALS DATE INSPECTOR SIGNATURE
COAST SIGN INC. (714) 520-9144-
1345 S.ALLEC ST. LIC. NO TEMPORARY R POLE
ANAHEIM, CA 654238C45
UNDERGROUND CONDUIT
ARCHITECT OR ENGINEER: TEL. 0: UFER GROUND
LIC. N0: ROUGH CONDUIT
ROUGH WIRING
MAIN WATER LINE
PLASTIC Y/N METAL Y/N
UTILITY COMPANY OT IED
REPORT ID: DPR265 ROUTE TO: BS0508
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 • LECTRICALMT_,
DEPARTMENT OF PUBLIC WORKS 9071 LAS TUNAS EC-0508-97`'1-2020-020'
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA
PHONE: (818) 285-0488 EXT:
LEGAL ID: FEES PAID Bp E
TR: 3623 LT: 105 5 29�EMEAD—BC
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917801832
ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET: HERMOSA
5387-012-018 Al PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 596 GRID: H3 LOCALITY: TEMPLE CITY
A5 PLAN CHECK 369.71 DOL 369.71
TENANT: F1 120V, 15/20A BR CKTS 8.00 SR 139.20 IWUED 0 PROCESSED BY: PL Y: EXPIRES ON:
G1 OUTLETS-LGT,SW,RECP 3.00 OUT 5.85 12/02/97, UT 12/02/98
G2 LIGHTING FIXTURES 10.00 LGT 19.50 1
OWNER: TEL. NO: G3 POLE MOUNTED LIGHTS 8.00 POL 18.00 FINAL DATE FINAL BY: E:
BANK OF AMERICA - JT TRANSFORMERS, 75 KVA 1.00 XFM 86.40 S//
333 HOPE ST K1 SIGNS, OUTLINE LGT 1.00 SIG 38.85 7/
LOSA 900711406 LA 100 AMP PANELS, MCC 1.00 PAN 38.85 DESCRIPTION OF WORK
LB 200 AMP PANELS, MCC 2.00 PAN 77.70 ALL ELECTRICAL FOR NEW DRIVE THRU RESTAURANT
LD 400 AMP PANELS, MCC 1.00 PAN 76.05
PPLICANT: TEL. NO: TOTAL FEES 897.86
THE GUTIERREZ PARTNERSHIP (909) 598-1518-
404 S. LEMON AVE. #7 SPECIAL CONDITIONS:
WALNUT, CA
CONTRACTOR: TEL. N0: ®Q APPROVALS DATE INSPECTOR SIGNATURE
BHF ELECTRIC (818) 915-8504- 9 ��B
2136 IDAHOME ST LIC. NO TEMPORARYPOWER POLE
WEST COVINA, CA 91791 720552/C10
UNDERGROUND CONDUIT
ARCHITECT OR ENGINEER: TEL. 0: ® / ER GROUND
THE GUTIERREZ PARTNERSHIP (714) 598-1518-
404 LEMON AVE #7 LIC. NO: ROUGH CONDUIT
WALNUT, CA 91789 C-15523 I �,�, 1
ROUGH �;G
MAIN v
P u r U C C-71)FO a"C' I PLASTICTER Y/NLINE METAL Y/N �
�— // UTILITY COMPAN 0 I ED
Fl
REPORT ID: DPR265 ROUTE TO: BS0508
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 LECTRICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9071 LAS TUNAS EL 05Q89B.1-1-1.200 0
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (818) 285-0488 EXT:
LEGAL ID• FEES P ILD DDRZSS
TR: 3623 LT: 105 �ROSEMEAD BJ�
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP-EIr91780'f832
ASSESSOR INFORMATIONNUMBER: NEAREST CROSS STREET: HERMOSA
5387-012-018 Al PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 596 GRID: H3 LOCALITY: TEMPLE CITY
G1 OUTLETS-LGT,SW,RECP 20.00 OUT 39.00
TEN G2 LIGHTING FIXTURES 15.00 LGT 29.25 rSSUED ON: PROCESSED BY: PLAN BY: EXPIRES ON:
TOTAL FEES 96.00 11/12/98 UT 11/12/99
OWNERUSSI:FAMILY TRUST (626)L304-0456- FINAL DAT 2FINAL CODE:
5829 ROSEMEAD BLVD.
TEMPLE CITY, CA •ESCR PTS IO 0 R
ECTRIC RE .1 0 FIRE DAMAGE
APPLICANT: TEL. NO:
ARGO SERVICE CONTRACTOR (626) 285-6059-
88 77 MISSION DR. SPECIAL CONDITIONS:
ROSEMEAD, CA i�'QELES CO
CONTRACTOR:E CONTRACTOR TEL. N285-6059- �r®� /A� APPROVALS DATE INSPECTOR SIGNATURE
8877 MISSION DR. LIC. NO TEMPORARY POWER POLE
ROSEMEAD, CA 91770 632879 C10
UNDERGROUND CONDUIT
ARCHITECT OR ENGINEER: TE 0: UFER GROUND
LIC. NO: 1111111 OUGH CONDUIT
ROUGH WIRrNG
MAIN z-
�(� G IL_,�C V V ®IFIC" PLASTICTER Y/NLINE METAL Y/N
T L TY COMPAN7_07MEND
6r o
El
I
C/ El
Z"
46Z" 0
service'Thai
REPORT ID: DPR265 ROUTE TO: BS0508