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Home My Public Portal About5573 ROSEMEAD BLVD_ELECTRICAL_2/12/2015_v " COUNTY OF LOS ANGELES TEMPLE CITY N 0508 ELECTRICAL PERMIT DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS EL 0508 1502120034 BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 PHONE: (626) 285-0488 EXT: LEGAL ID: BK: 105 PG: 86 PC: 10 (FEE DESCRIPTION: ASSESSOR INFORMATION NUMBER: 1 5387-032-059 IA1 PERMIT ISSUANCE FEE IK1 SIGNS, OUTLINE LGT TENANT: WE MART OWNER: TEL" NO: WILLIAM (626) 675-1183- 10501 VALLEY BLVD. APPLICANT: TEL. NO: KYI CHOW SHAR (626) 444-6027- 9868 KALE STREET S EL MONTE CA 91733 YEEB PAID j 1 (APPROVALS 1 BUILDING ADDRESS: INSPECTOR SIGNATURE (TEMPORARY POWER POLE I 5573 ROS EMEAD BL QUANTITY: UDM: AMOUNT: TEMP CA 917801802 ARCHITECT OR ENGINEER: TEL. N0: PIREVIC NO: :1-ro IUFEA GROUND I 1 NEAREST CROSS STREET: BROADWAY IROUGH CONDUIT 27.80 1 THOMAS PAGE: 596 GRID: H4 LOCALITY: TEMPLE CITY CA 1.00 SIG 38.90 IMAIN WATER LINE (PLASTIC Y/N METAL Y/N I TOTAL FEES 66.70 (ISSUED ON: PROCESSED BY: PLAN BY: 102/12/15 SR BY: DESCRIPTION OF WORK INSTALL OF SET OF INDIVIDUAL CHANNEL LETTERS uUNl'LiAu'1'ux: TEL" NO: KYI CHOW SHAR (626) 444-6027- 9868 KALE STREET LIC. NO SOUTH EL MONTE CA 91733 652665 j 1 (APPROVALS 1 DATE INSPECTOR SIGNATURE (TEMPORARY POWER POLE I (UNDERGROUND CONDUIT I I I ARCHITECT OR ENGINEER: TEL. N0: PIREVIC NO: :1-ro IUFEA GROUND I 1 IROUGH CONDUIT 1 TROUGH WIRING I IMAIN WATER LINE (PLASTIC Y/N METAL Y/N I I (UTILITY COMPANY NOTIFIED( I • ADDITIONAL DATA ON FILE REPORT ID: DPR265 ROUTE TO: BS0508 OWNER -BUILDER DECLARATION LICENSED CONTRACTOR'S DECLARATION I hereby affirm under penalty of perjury that I am exempt from I hereby affirm under penalty of perjury that I am licensed under the Contractors' State License Law for the reason(s) indicated provisions of Chapter 9 (commencing with Section 7000) of below by the checkmark(s) I have placed next to the applicable Division 3 of the Business and Professions Code, and my item(s) (Section 7031.5, Business and Professions Code): Any license is in full force and effect. city or county that requires a permit to construct, alter, improve,/te�rr""� /' demolish, or repair any structure, prior to its issuance, also •License Class �L License No. 6 requires the applicant for the permit to file a signed statement that he or she is licensed pursuant to the provisions of the Date 2 -17--&Contractor Signature Contractors' State License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions WORKERS' COMPENSATION DECLARATION Code) or that he or ah Ia exempt from licensure and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): U I, as owner of the property, or my employees with wages as their sole compensation, will do (✓) all of or U portions of the work, and the structure is not intended or offered for sale (Section 7044, Business and Professions Code: The Contractors' State License Law does not apply to an owner of property who, through *employees' or personal effort, builds or improves the property, provided that the improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the Owner - Builder will have the burden of proving that it was not built or improved for the purpose of sale.). U I, as owner of the property, am exclusively contracting with licensed Contractors to construct the project (Section 7044, Business and Professions Code: The Contractors' State License Law does not apply to an owner of property who builds or improves thereon, and who contracts for the projects with a licensed Contr9Ftor pursuant.to the Contractors' State License Law). U I am exemdt from licensure under the Contractors' State License Law for the following reason: By my signature below I acknowledge that, except for my personal residence in which I must have resided for at least one year priorl to completions of the improvements covered by this permit, I cannot legally sell a structure that I have built as an owner -builder if it has not been constructed in its entirety by licensed contractors. I understand that a copy of the applicable law, Section 7044 of the Business and Professions Code, is available upon request when this application is submitted or at the following Web site: htto://www.leginfo.ca.gov/ralaw.htmi. Date: Signature of Property Owner or Authorized Agent WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. I hereby affirm under penalty of perjury one of the following declarations: I have and will maintain a certificate of consent to self - insure for workers' compensation, issued by the Director of Industrial Relations as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. Policy No. I have and will maintain workers' compensation insurance, as required by Section 3700 of the labor Code, for the performance of the work for which this permit is issued. My workers' compensation insurance carrier and policy number are: Carrier Policy Number Expiration Date Name of Agent Phone Number 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 of California, and agree that, if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions "�—� I -(s Sigallof Applicant ate LOBBYIST ORDINANCE CERTIFICATION Complete this section for permits in Unincorporated Los Angeles County only This is to certify that I, as permit applicant, am familiar with the requirements of Los Angeles County Code Chapter 2.160 at seq., (relating to the Los Angeles County Lobbyist Ordinance) and that all persons acting on behalf of myself complied and will continue to complply therewith r-thhrou'gh the application process. G Iz 1 I � 5I0qT7__ Applica t (Print Name) Applicant Signature I JAL Cu LiM Slc,�t— t-(z-_ot(- Company Name Date JOB ADDRESS LOCALITY HAZARDOUS MATERIAL DECLARATION Will the applicant or future building occupant handle a hazardous material or a mixture containing a hazardous material equal to or greater than the amount specified on the hazardous materials information guide? Yes ❑ N o ❑ Will the intended use of the building by the applicant or future building occupant require a permit for construction or modification from the South Coast Air Quality Management District (SCAQMD)? See permitting checklist for guidelines. Yes ❑ No ❑ I have read the hazardous materials information guide and the SCAQMD permitting checklist, I understand my requirements under the Los Angeles County Code Title 2, Chapter 220 Sections 220.100 through 220.140 concerning hazardous material reporting and for obtaining a permit from the SCAQMD. ASBESTOS NOTIFICATION ❑ Notification letter sent to AQMD and/or EPA ❑ I declare that notification of asbestos removal is not applicable to addressed project. bECLARATION REGARDING CONSTRUCTION LENDING AGENCY I hereby affirm under penalty of perjury that there is a Construction lending agency for the performance of the work for which this permit is issued (Section 3097, Civil Code). Lender's Name Lender's Address By my signature below, I certify to each of the following: I am the property owner or authorized to act on the property owner's behalf. I have read this application and the information I have provided is correct. I agree to comply with all applicable city and county ordinances and state laws relating to building construction. I authorize representatives of this county to enter the above -identified property for inspection purposes. Signature of Property Owner or Authorized Agent �te z-tZ—t�