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Dee s-A a46 1 APPLICATION FOR PERMARTDIENT OF BIIRIMG AND sAFETY ELECTRIC
CO OF LOS ANGELES
J O 1 OI R
NAME"4_00, DISTRICT NO. GROUP ZONE PERMIT NO..'
1yU-' ADDRESSREADY MR DATE
CITY /_ ,(/fEL NO VED 9 FIRST INSPECTION ISSUED
COUMTY
CERT MO / EXPIRES
APPLICANT FH.L IN HEAVMY OUTLINED PORTION,ONLY
DESCRIPTION OF WORK AUURess15-)13,Z
NUMBER OF OUTLETS ON CIRCUITS LOCAL ")
LOCATION BY ROOMS
NEAREST
—LIGHT ouTLcre JEW Pwae r,Xr c
CIRCUIT A IB ICID I Ef IF IG I H 11 d' NAME i
= MAIL
3 ADDRE'S8 /t/
° CITY v TTLNo� 13
1 AM THE LE AL POSSESSOR OF TH6 ABOVE IAS
ANGELES COUNTY CERTIFICATE OF QUALIFICATION
• �� tL.tCTRICIAN
I AM TM LEGAL OWN=OF THE PRO DESCRIB®
A90VIC /�O
(„/ awNaR
CORRMHON$
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R
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Tor
NO OF OUTLETS 8 ACE APPROVALS
NO OF FIXTURES S DATE INSPECTOR'S NAME
NO OF MOTORS H P S CONDUIT
NO OF SIGNS TRANS S WIRING '✓� 7
NO OF RANGCS OR HEATCRS S FIXTURSS
MISCELLANEOUS POWER aa
PERMIT FEE S UTILITYCO i
NOTIFIED 'P –I91) L 1
TOTAL FEE FINAL
WORKERS COMPENSATION DECLARATION CE 806 ta,Bt , APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self CE 806r,
insure or a certificate of Workers Compensation Insurance COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified copy thereof (Sec 3800 Lob C )
Policy No Company FOR APPLICANT TO RLL IN JOB
ADDRESS
Certified copy is hereby furnished New Residential Bldgs 8 Pools EACH NO FEE
❑ 1 8 2-Famd Ft $ — S LOCALITY
Combed copy is filed with the county building mspec- Y SQ
hNEARESTon department Multi family Sq FI CROSS ST L AICILdk�–fZ
Date Applicant Residential Swimming Pools OWWR OR
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERSOutleU Rec�Li ght 1 Sw� MAIL
COMPENSATION INSURANCE t , ADDRESS
(ThIs stolon nod not be completed N the work Involved /� Fust 20
P 6T Total No to Additional CITY _ Tel No
the permit a for one hundred dollen(f100)or los ) PLAN CHECK
that m 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 Worke;A Compensation ws Lighting Fixtures Fiat 20 IADDRESS --
Total No 4:22 Additional
Date�� �q A Appbc CITY Tel No
NOTICE TO APPLICANT If a er making this Certificate o Fixed Appliances Not Over 1 HP PERMIT
Exemption, you should become subject to the Worker Range_ Heater_D W _ APPLICANT
Compensation provisions of the Labor Coda, you must fort Oven _ Dryer — W M — ADDRESS
with comply with such provisions or this permit shall be Top — FAU —WH _ _
deemed revoked Hood — Fan _Other_ CITY Tel No
LICENSED CONTRACTORS DECLARATION LICENSE OR
I hereby affirm that am licensed under provisions of Chapter 9 Disp — Room Air Cond REG NUMBER Clau
(commencing with Section 7000) of Division 3 of the Business Power Apparatus 8 Large Appliances DISTRICT NO D BY
and Professions Code and my license is in full force and effect IL
Size 8 Type HP KW KVA or KVAR O
License Number Lic Class Up to 1 Incl - FINAL - V
Over 1 to 10 Ind ��� '�Q VALLDATION 0
Contractor Dote Over 10 to 50 Incl
11FINAL
I am exempt under Sec Over 50 to 100 Inc BY
8 8P C for this reason Over 100 r—_r =
Dote Services Swbd MCC 8 Ponelboards
0 200 Amp Under 60D V
Signature 201 1000 Amp Under 600V
❑
Exemption for Reg MaiOver 1000 Amp or Over 600 V
Maim Elect
SINGLE FAMILY Temp Power Pole 8 Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hefeby affirm that I am exempt from the Contractor is License
Law for the following reason (Section 7031 5, Business and Additional Sign Branch Circuits _ 9 8 6 1 Q
Professions Code)
❑ I as owner of the property will do the work and the Misc Conduits 8 Conductors - # • s • 2
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)— ,
7044 Business and Professions Code) •
( • • 2250
CONSTRUCTION LENDING AGENCY •�• e 2 2'5 0 TLS
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) 02 1 6 –8 3
(Sec 3097 Gv C )
PLAN CHECKING FEE 140 _
Lender s Name
PERMIT ISSUING FEE
Lender s Address
I certify that I have read this application and state that the TOTAL FEE
above information a correct I agree to comply with all County -
ordinances and State jaws regulating Electrical wiring, and
hereby authorize representatives of this County to enter upon -
theove mentioned pr party for inspection purposes
�n SEE REVERSE FOR EXPLANATORY LANGUAGE _
ife FL� C!3
Signature ofuP rnwt Date
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 ELECTRICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS EL 0508 0708070025
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE (626) 285-0488 EXT
LEGAL ID FEES PAIDBUILDING ADDRESS
ON FILE 5329 TEMPLE CITY BL
FEE DESCRIPTION QUANTITY GUM AMOUNT TEMP CA 917803149
ASSESSOR INFORMATION NUMBER NEAREST CROSS STREET OLIVE
8590-006-007 Al PERMIT ISSUANCE FEE 27 75 THOMAS PAGE 597 GRID A4 LOCALITY TEMPLE CITY, Cl
LB 200 AMP PANELS, MCC 1 00 PAN 38 85
TENANT TOTAL FEES 66 60 ISSUED ON PROCESSED BY PIAN BY EXPIRES ON
08/07/07 SR 02/03/08
OWNER TEL NO
Y CODE
NOSRAT/FARZANEH MOSSAYEB FAR7ANEH (626) 286-9538- I FSjU�p/g
15329 TEMPLE CITY BL
1TEMP 917803149 DESCRIPTION OF WORX
(UPGRADE SERVICE PANEL TO 200 AMP
APPLICANT TEL NO
ISAME AS OWNER
I SPECIAL CONDITIONS
ICONTRACTOR TEL NO APPROVALS DATE INSPECTOR SIGNATURE
SAME AS OWNER -
LIC NO TEMPORARY POWER POLE
(UNDERGROUND CONDUIT
ARCHITECT OR ENGINEERTEL tL0 I UFER GROUND
_ I
LIC NO ROUGH CONDUIT
ROUGH WIRING
MAIN WATER LINE
IPLASTIC Y/N /N
UTILITY COMPANY NOTTIFIED
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REPORT ID DPR265 ROUTE TO 850508 � 1
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