- 2260 IMPERIAL HWY E S10 (3) �tAC S iD BTH oop_
• ELECTRICAL PERMIT
APPLICANT - _ City Of El .Segundo _
CIL FC_s ("TINl T QC- BUILDING SAFETY DEPARTMENT
ADDRESS _y CITY �. [ 21P PHONE Tract Lot I PatCel 4,
r(�YJa.a, a , ._ z`s53 Page
NAME I Cenlly that I hate reed this application and!date that the above information is Correct
u Gal1L,.ht i-S f\ 'a r -A L_ C �-- 1 agree to comply with an city and county ordinances and state lave reladnp to buiubnG
3 AODRESS PHONE ConslruCtion, r auctions repre nwtwae of this any to enter upon the above
p .� 0 fo rnspectlen purposes _
CITY �'L,1'�l�ia) �ArEIZIP a IL—'J?_
NAME
W - —99
Signature of n1 of Agent ✓ Data
! ADDRESS I,/1 / PHONE y
cCITY '1 / STATEIZIP P C No No Plere Revd
W NAME NEC / Date r M I Comm ,todus
ADDRESS PHONE SERVICE N MBER EACH FEES-
y21 CITY �� STATEIZIP Service Size
NAME Service over volts 60 00
MAILING ADgR6$$ Additional M -
/tiL- . r I.I Panel Board
c CIT>C"�S', _^ ( i� TELEPMj�I _ SWITCHBOARDS (other than service sections)
aa'a STAT�G,4 ZIP 1040
C CITY LIC NO C. 1> First Section -
AdditC (
i 30 NO
I hefeey adlm under peony a p"Met I am hdnaad upper povnom d Chapter 9 I n 1 - _
V (mmmenc rq WM Section 7000)IT Dr."3 der B.Omen so Prolesarons Coe sect Over 600 VON Sections 60.00
My h.or e he JF. Weed.
Lesson own -It Uc No Additional Iona 5500
Oar 17,07 -;Cg codr Signature OUTLETS
WORKER'S COMPENSATION DECLARATION Switch, Light. Receptacle 50 .L
tel Light Fixtures 50 B S
I ono enkm upper peoq d W,Wy Meet Me folhawing declerenna -
_I heye d,d woe rriauinal s drdote al consen,ro sett inswe toe workerppliance DOmBatIC 400
2 coihpenned in prdkwd he by section 07W of Its Labor Code for per Appliance Commerctal 8 00
of welt mr:MM,pr perm)r nand
h- Ira.M wig Mak a workers
pOnui POWER EQUIPMENT HP OR KVA
r7 of sr .n `fa 1JyAsrfo�l re worts for Me r rla permit n naue0
f1��^I���/fnn ��PdI4y Norm n ter recarrier UP TO 5HP 6 50 SO I-100 HP 33001
(TNa swim rase red w erAnprtee d the drmn n for od hundred ponds(slo%d ins Oil5 1 to 20HP 10 00 Over 100HP 50001 - -
p _I deny sin M me paddmr,d d yr work foe weep da pafmn n Issues I anon nd1 20 1 to 50HP 1 115001
t.s en,pby any omen many med,m so n r mamma subject r the worker companasson
y taws OF California,and agree that it I should dame sue Wcl 1. a'compemahon Temporary Power Pole 2000
r= mmnemts d Settle 70C d its Labor CM, I I Py wl t rsa
Permanent Power Pole 20001
Provnbna
SynaNr Fire Warning, Communlcetfons, Emergency, Control Systems, Smoke
'3 WARNING Falco meecrew eked dmdnndn cov.mgsl NawNl 811p ah I Detectors& Sf nal Svstem
subject n employer r mmr p Min and rnd fees up r one hundred Mou ur d QUANTITY
dot (3100,000),In admit maw mat of compensation damages as pra ded for In
section 7706 of Ma Labor Cosa,mtnmt ern anomey a tees Control Equipment for above systems
i ofaay anon udrr parody of nardury two I em.seme,vam Me Caoacrr.License Law "-QUANTITY
for Me mOowmg reason(se: 70315 Business ad Profeaabm Code) Any i Or corny Investigation Fee IDO 00
whkh remnlrea a drmh,o sonawq alter immow demohah o,repea any a re poor
to Its inventory else returned,Me apphmm tar auen drm1,us his a sign ant m Mal ha
d sne ts Iralaatl ptusuam ro yr prwivoro of ttre Conrtedms LidnaO (Crap 9
Icorninandq tlr Sedorl]cool d Dntsron d Me eusineas end Pro sons Coael or
_ Nat M m ad Is,"SMIA thsreffem and Me Assn for Ins.Ilegod a peon Any violation
of Senn 7Oa1 5e q nn(m Wpr n.UMru,a ma apple.,Io a wn Mnolty of
not more Man q
i
W ( 1 I,ss owdr d Ms popery a e b u eumas as tho sole compensehre wit
C d Itsok,m,e w Ma soucNn n rmy ot a sped Ire saw(Sec m v sa>0 Bune and IT FEE (Sub Total)
�.I Professions Cod n) Tha Cptlndt Lltc rise Law does nor appry to an owner of a pro,wiry
*no Men of reproves Erred ao whe does Such on,himsafl or mrough nn or Mf own RKS Plan Cheek Fee
emyloy!ea powder sot welt repovemena are not MMWJMJ of pulsed for saw If h ' '�
W nOWeWq Id Wllddng of onwin tamed n SOW W Ilh n one year of COTOIWIIOn the owner PI Ret Fee i1
2 bdbsr will have Me bluesn d pria ng Mal se She cod not autld or,mproye for Its
3 proposed ear) _
( )f.o owner in Er popery am axddnefy cmared,p with Speond mnvacrora to Issusnae Fee $15 00
construct Ma project(semen 70e4 B...asap Pm'.sains Coo. The Comracmre / ./r
Ldaoe �E fro
Law,de to anne s not sapty owner of prodry who augd o,anis.w a Mefen and Issue Date r TOTAL FEE If
-no drrV.M fOr tun projects with a pdrum, .tit)held.parauenl,o the Condfetrr Ry
LawmeLaw) READ CONDITIONS BELOW - --�/
( ) I m uampt under sec_ B a PC roc Mn roeaon The work authorized by Issuance of ads permit is subPact to all the rules L
and regulations sat forth In the ordmcni'.es and amendments 01 the Gy of EI
owner Segundo,and the lease of the State o1 California in regard to such work,and
all amendments,thereto
CONSTRUCT. N LE! 1NG AGENCY Thus Permit bewmee nXiand voia if work is not commenced within one
f>C I / hundred eighty(180)days from date of Isauatice,w If work M s,uspenlled W
us hereby M m1 wdsr Dnatry ma arcs n a conaoucdn rneMp spar y ra My ame during.art uaron for me Same period Of ame,W n work
Za+irdannalld d E,e work / Z ismon n naiad(Sec 3097 cn C) m V*Wmn of the Gy Ordtnance or States ewe governing dams us done
Lender Noma
i VALIDATION
L.ndrt Andras
Distribution GREEN & BLUE (Dept) YELLOW (Apphcnt) da FORM E 103 R. I/95
INSPECTION FMCORD
APPROVALS DATE INSPECTOR'S SIGNATURE NOTES
TEMP POWER POLE
UNDERGROUND
ROUGH
WALLS
CEILING
SERVICE
UTILITY NOTIFIEO
FINAL
REMARKS