TEMP POWER® v. Property
Address loat)
—
Pt1L tJ
Phone
Property 949-623-3700
Owner Acaress. to offleml - — psi
27101 UE TA E L, TE#340, MISSION V EJO, A 92691
Name It! t r) Phone
ii ttt A N Cl ALES 951-293-1467
App275 mea
PE t L E IS, CA 92751
Nam
S.R. Y LLC POWERPLUS DBA hen 715-751-7551
Address
Contractor 12101 E GUM ST, ANAHEIM, CA 92806
taten! sI Business
i ns 805 s 1255
`ton INSTALL ONE 240 AMP U/G TEMP POWERLE AND FOUR SUB POLEST POWER 11 ENT PHASE
of
work
1
We Contact? [ I Owner DjApplicant 3 Contractor Other (please provide information i
Applicanes Signature: Date:
Fbr Office
7 Project Name
Project it IF Uate!ved 150toIu
-1134,5— 16R
It Fee SMIPr u t Paid
LIL--I— 91,50
ValuationFootage
Commercial i ResidenfiRl Dwelling
City or Lasty-I
'Mi; 7U3e4;39
l
Lig rq,5r, r Z0JT t a mac-j ' t,�XA i `-jaq a ndreaay turmal treat i am licenseti tali .r 9 (cam a cnvin -hn b.cca
d1106) FlA9e3i.a® 5tit Me =3tR:sL MU P l.ae0aoacunc,-id my Feunau'Is®n pill force sdUtli;UL
License Class Lie. Nin 9K589 urate; I"AflIS
Contractor 3ignaturc:
UEl7LFLrQN tr IN & arerevy affirm unit i am exempttrom uae Contractor's Cleanse LOW ior Me zdilowin reason (:se.. ium.3,
MZI Civ1la: A®;. city or UoMit7- Waica —tzi ® U Fu. al to tomstruct, salter, i -F ae, dvea —hl Nrl; or izir-y 3;ruumm pri.r o,
issuance, also requires the applicant for such permit to file a si ded statement that he or she is licensed pursuant to ute provisions sam tue C on ctor's
MOM LaW (Chapter v [commencing witI1,3ection r ir) oru'ves'.- i r in. -11 iv tr) ve inat no va me i, Inc pt fficrernim
un it ,hc 7-iT Isar r allvgcd uxu pri-n, An, vi*.I a:-'1vn l Section .7U3 t...5 f7.T -., capvl'. , ruras p a aaur subjects the applicant to a civil penalty: of not
more Man five hundred dollars
1, ortne .� l°t�, u! .7 w lojew- I .. ®-1l Ow tnr -~irk, _0 tnc „tructer. .3 aomt lntwa vU or olIc d
1`67 3.1, (Scc- 7044, Bu3inuss -d Fmlcazuumi Cock: I IL; .n .taaA's Ua nse Law dues not apply to an owner of }Property who builds or improves
tnereon, anti win) Zides sileR wom nimseaFdr nerseia or tHr uFn nis or icer own employees, proviUctl Mat seen improvements am not intennea �®
11, no-07-7, trio owllui--F 0.&®® ags PCa e�nt z hold.- atpi2n no C .vrry Fw-.-nq raw Wfl.Tabtnldor - Il ftsae- rho hn cri of p -igns
that lie or she did not build or improve for the purpose af°sale).
;i I, as owner or Me property, Ifni exclusively contracting wiM iieensed contractors tv venstruvt rn vvt (bee. dU214g
Coda 111c Commuter'. Licureic Law dov. not rF1,ly to dna, o axr or pram a%,ho 5thId3 or "aa pi-vas3 Mi,rcm. and arohu rontraets for such projects
wiffl a contraetor(s1 licenses pursuant to the Contractor's i-icense Law.).
1 z®® W--UPRIVI mi 'op 511w U at r®,'ur fillin -vain
I➢.®eaOwner's Signature
%VU C,ttb' C lM MM5tY 1 ION FILCEAKA l ION I ni:M5, EMPM undo C"JtJ- -1 Ce- M ®RC l tel. rullo h`is aud�a. a I'Mmi.
o l have and vrill maintain a certificate of consent to self-leisure for i rkers' compensation, as provided for by Section 3700 of the Labor Cade, for
We perliarmance or Me worK Tor wflicn anis permit is issue
ri I Inzvv zmd ,.®il a mmunas .Pkr ' Lvnasi..rR3.tnon s n��e Win® y ®,� ,qm va fi., Smziun 37 of lTI- Lsub.r .av,. I-i c rlurm—muc VI & work for
which this 1t is isstaed,_' y workers' rnpensation insurance carrier and ley number are:
u-r W.- EXECUTIVE ISIS INDEMNITY .167-IN..
( Inca .VC6gR oac noz b... plro�d nr.. c k ,rmi. to rur one nal arcaMimic. oau ) ar k3j)o
a a certify Mat In the performance sof the work for wnicu wis permit is issued,1 And not employ any person in any manner so as to uccome swiJeet to
IS. i® ... ®r it ®:iA, —U 75.-,U mzt it I mvis l fiveU v vwt tai Env ®,v ve ' ea 3uvtto. -1/90 l
the Labor Code, I shalt forthwith comply with those pro isto
nate c 25113 Applicant's 3i nature �
AKNIN „ rAiLUKI: Ise S is iaKr hKb'MMAI I N r v ks UNLAWPUL, AND NHAEL bULULCI AN I;MrLOYt
TO CRIMIN L PENRLTIES, AND CIVIL FINES LII TO ONE HUNDRED 'THOUS hi DOLLnRS CS100,0001a IN ADDITION TO THE COST
Or C mFrr oA i liraq, VaratiiCiEzi is FKUv iuEL) FUK Ian 3EU. ) ir/ia KJr i tip int DUK CUUt, IiN l r.31; 2Z is l l UMN r- t'3 r1:1:3 e
(70(70mi I mu I N LLNUINIG AGENCY 1 aa.ffirm uamdcr p ri ak., of pvUrn Ulmaaom `13 . Viia an®-.Tion.Ic"aSRb 55ciioj Iur tn� pry tsea mem MEV
oruie war h witic dais pe it is assnes;13eQ iia r4 ivie a .a.
A S LI A ' 4b a816Y ' U I Idly &At I &Ane m d R.3 —id zp6W6G ffia; gic 88 -ic is currvcL, 1 ZAs.— to comply with..11
city ana county or-Umances anu state laws relating to ulAMing construction, anti nerevy arum ize representatives oFuae City orr-astvale to enter upon
to P lid- s i
rt
3rit%v4iNwag Ova-4,LALrL 11126118
3i n attire or �pptieaantrrtractor or wnarp rint Rome irate
7
C @ b tti ritt,5t m .i v t „lfi ,1v, r,}Ytli dYt
�-P
t VAP")
rT
rr
lip
wall�.
W
PN
INV
jo
Un IC30
LID
Lun
W rr
'19 CEO
wo
to :;a
ES
CT
m
r
t
t i 1
11a
r
r
s
1
1
i
s
tfn
uti v
00
77
'R P • 4 4 1 � ��Ml � Yd%Li: } 31x,2165 Hnv it ::
— ok
. u .. ,.•..£��. .,,.. &fir ,., z ,... - ;+�