HomeMy Public PortalAbout9943 BOGUE ST_Electrical__ WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12-91)
76A663 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 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
ADDRESS l Z
Certified copy is hereby furnished New Residential Bldgs &Pools NO. EACH FEE
$ $ LOCALITY
❑•.- , Certified co is filed wdh,the count building inspection
1&2-Family,Sq Ft. l
y g p Y q• COSNEAREST N
department. Multi-family S Ft.
Date Applicant Residential Swimming Pools MAPBOOK
PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' Rec. Light�—Sw OWNER OR
Outlets
COMPENSATION INSURANCE ets �_ '^ FIRM NAME
First 20 v �
This section need not be brr leted if the work involved b <
permit is for'one hundred dollars($100)or,less.) Y MAIL
the Total No Additional ADDRESS 9 9 \ b U
I certify that in the performance of the work for which this permit 'CITY ' G� T�.l No
is issued, I shall not employ any person in any-manner so as t0 PLAN CHECK
become subject to the Workers' Compen tion Laws. Lighting Fixtures First 20 APPLICANT
Total No. Additional ADDRESS
Date �� -Applicant RESIDENTIAL APPLIANCES NOT OVER 3 HP.
NOTICE TO APPLICANT,..,-If, aft r g this,Certificate of CITY Tel No
Exemption,you should become subje to t ,Workers' Compensation OTHER APPLIANCES NOT OVER 3 HP.
provisions of the Labor Code, ou must f rthwith comply I with such PERMIT ,, p��� �Gm L�
p Y p y Power Apparatus&Large Appliances APPL ANT Na L
provisions or'this permit shall be deemed revoked.
LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS 2-L151- Jo (,t t, Q,(_-7
I hereby affirm that I arri'licensed under provisions of Chapter 9 �_ Over 3 to 10 Incl
(commencing with Section 7000) of Division 3 of the Business and CITY G�C Q &,-t Tel No 4 c-t7 5-7
Professions Code,and my license is in full force and effect .Over 10 to 50 Incl.
Over 50 to 100 Incl. REG NNUM ER SE OR �'D 6 Class.Z'(.7 d
5 co Over 100 DISTRICT NO PROCE ED BY O
License Number u Lic Class ��� U
' /•N Services,-Swbd,MCHC&� el and "- C'e� �L satiG'
FINAL
Contractor �i V6�� �,1Date L/ lZ� 0-39, -Under 600 V ' DATE
❑ 400-1000 Amp Under 600 V tP C�
I an exempt under Sec VALIDATION LV
Over 1000 Amp or Over 600 V FINAL (Z
B"&P.C.for this reason ` BRANCH CIRCUIT FEES BY
Date: 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 y
HOME OWNER-BUILDER DECLARATION' 'CT -4
I hereby affirm that I am exempt from the Contractor's License Law Sign with One Brar ch Circuit €t 4
for the following reason (Section 7031 5, Business and Professions Additional Sign Branch Circuits30`" E_ vol j
Code) .:
❑ I,"as owner of the property,will do the work and the structure Misc Conduits&Conductors 1 WENS
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) TI_IjhL � 20
and Professions Code). C
K 85.20CONSTRUCTION LENDING'AGENCY CHECK_
I hereby affirm that there is a construction lending agency for the CHANGE
performance of the work for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total)
Civ.C.)
PLAN CHECKING FEE 000I_01I1 6114i.%i
Lender's Name
PERMIT ISSUING FEE -+t-tr i9:59
��7._ AM
Lender's Address
I certify that I have read this application and under penalty of purjury state TOTAL FEE �C/ -
that-the 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 above-mentioned property
for inspection pu es. SEE REVERSE FOR EXPLANATORY LANGUAGE
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SIGNATURE OF FlIERMiTTY DATE
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 ELECTRICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS EL 0508 1106010028
'BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE- (626) 285-0488 EXT: ,
(LEGAL ID: FEES PAID BUILDING ADDRESS:
ITR: 16557 LT: 5 9943 BOGUE ST
I IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT: 1 TEMP CA 917802632
IASSESSOR INFORMATION NUMBER: I I NEAREST CROSS STREET: BROADWAY
18588-014-022 1A1 PERMIT ISSUANCE FEE 27.80 THOMAS PAGE: 597 GRID: A3 LOCALITY: TEMPLE CITY, Cl
I IG1 OUTLETS-LGT,SW,RECP 21.00 OUT 40.30
TENANT: 1G2 LIGHTING FIXTURES 14.00 LGT 27.20 JISSUED ON: PROCESSED BY: PLAN BY:
IH2 RES GRBG DISP LT 3HP 1.00 DIS 10.90 106/01/11 SR I
I 1H3 RES DISHWASHR LT 3HP 1.00 DIS 10.90 I I
(OWNER: TEL. NO: I TOTAL FEES 117.10 IFINAL DATE FINAL BY: CODE
IVEENSTRA BARBARA J (626) 286-5330- I 1"
19943 BOGUE ST I - '1W)
ITEMP 917802632 1$ESCRIPTION OF WORK
(ELECTRICAL FOR NEW ADDITION AND REMODEL KITCHEN AND BATHROOMI
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(APPLICANT: TEL. NO:
IFIEL, JIM (626) 222-8803- I I
ISPECIAL CONDITIONS: 1
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ICONTRACTOR: TEL. NO: 1 1APPROVALS DATE INSPECTOR SIGNATURE 1
IFIEL, JIM (626) 222-8803- I 1 I
LIC. NO ITEMPORARY POWER POLE I I I
NONE 1 1-1 I
I (UNDERGROUND CONDUIT I I I
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1ARCHITECT OR ENGINEER: TEL. NO: 1 IUFER GROUND I I I
IMUTKA, JASON (951) 235-0276- 1 I I
I LIC. NO: 1 IROUGH CONDUIT I
1 NONE I I
IROUGH WIRING 1
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IMAIN WATER LINE 1
1PLASTIC Y/N METAL Y/N 1 I 1
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1 1 (UTILITY COMPANY NOTIFIED(
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IREPORT ID: DPR265 ROUTE TO. BS0508
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