HomeMy Public PortalAbout9028 BROADWAY_Electrical__ WORKERS'COMPENSATION DECLARATION 76-663 to/Bt APPLICATION FOR ELECTRICAL PERMIT -
I hereby affirm that I havee a a certificate of consent to self insure, CE-806G ,
or a certificate of workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof( a 38 - _p.)' '
POIICy No. Company' �' FOR APPLICANT TO FILL IN JOB qoodk
❑ Certified copy i5 hereby furnished. New Residential Bldgs.& Pools EACH NO. FEEADDRESS
❑ Cert'ied copy is filed withAFRO
nty building inspection 1 & 2-Family,Sq.Ft. S — S LOCALITY
NEAREST
Multi-family Sq.Ft. — I
-(� - Residential Swimmin Pools I1 •3 CROSS ST.
Date�� Applicant g' OWNER OR I I,
Vd
!� FIRM NAME
'CERTIFICATE OF EXEMPTIOWORKERS:;�I ,1t { +'MAIL
Outlets:Ree— Light— Sw. - �'1
COMPENSATION INSURANCE � 1
ADDRESS L
(This section need not be completed if the work Involved.by the -First 20 p
Total No. Additional CI`V I�� Tel.No.
- permit is for one hundred dollars ($100) or less.) `' - 'w'
1 certify that in the performance of the work for which this permit + r •_•. PLAN CHECK -
is issued, I shall not employ any per ..in a manner,so as to �••� t!(` 11�• t .� '( ;±; .APPLICANT
become ub at lie Workers'Com on aws. Lighting Fixtures First 20 \ { '4 :ADDRESS
,� Additional v,'
/ .0 TotaLNo. ,1 CITY ,- Tel.No.
Date Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO A PLICANT: If,,afte makin this Certificate of Q Jl'f'.�..-
Exemption,you should become subject to the Workers'Compensation s -Range_ Heater_ D.W. APPLICANT F••
provisions of.the Labor Code, you must forthwith comply with such Oven _ Dryer _ W.M.— ADDRESSJ,4450 0Aq1Jot4,q at,&
provisions or this permit shall be deemed revoked. Top — FAU _ W.H. _, ` ..� _` �j �• .p
LC7 WIIV 1LTeL No. .7
LICENSED CONTRACTORS DECLARATION CITY
.Hood — Fan _ Other_
.1'hereby.affirm that I am licensed under provisions of Chapter 9 LICENSE OR
(commencing with Section 7000)of Division 3 of the Business and - Diss. Room Air.Cond.
_ REG.NUMBER 171V11 Class.
Professions Code,and my license is in full force and effect, DISTRICT NO. PRO BY 6 ell O `
Power Apparatus&Large Appliances..
/�/y�',,,...//// /^} Size 8 Type HP,KW,KVA,or KVAR b x
License Numbeer]�/ /�yJ I Lie.Class '"` Up.to 1 Incl. FINAL - V
Contractor�/I/" Date 1 � - _ _ Over 1 to 10 Incl DATE. el VALIDATION O
❑ Over 10 to 50 Incl. FINAL U
I am exempt under Sec. Over 50 to 100 Inc. By d
B.&P.C. for this reason Over 100
Date: N
Services,Swbd.,MCC 8 Panelboartls !9 (�j D Z
.. 0 -200 Amp,Under 600 V
Signature 201 - 1000 Amp.Untler 600 V
' Over 1000 Amp.or Over 600 V
Exemption for Reg.Maint.Elect.
SINGLE FAMILY '' _ Temp.Power Pole& Appurtenances - 2
HOME OWNER-BUILDER DECLARATION Si n with One Branch Circuit t
I hereby affirm that I am exempt from the Contractor's License Law g ACCT.r
for the following reason(Section 7031.5, Business and ProfessiorisAdditional Sign Branch Circuits, _ 3K7 '31.01)
Code): i
Misc.Conduits&'Conductors " 1 'ITEMS
El I,as owner of the property,will do the work and the structure Other(See Complete Fee Schedule)._ TOTAL 31 -00
is not intended or offered for sale (Section,7044, Business - _ D
and Professions Code). -
CHECK 31.06
CONSTRUCTION LENDING AGENCY - - CHARGE. .00I hereby affirm that there is a construction lending agency for the ,
performance of the work for which this permit is issued(Sec.3097,. PERMIT FEE - (Sub-Total) -
Civ.C.),
PLAN CHECKING FEE - _ DOQD-0001 6/2390
Lender's Name - 1547 1 AM 8:F6
L Address
_PERMIT ISSUING FEE
cern's
certify ertify that I have read this application and State that the above TOTAL FEE •
information is correct.I agree to comply with all County ordinances ,
and State laws regulating Electrical wiring, and hereby authorize _
repryqtatives of this County to enter upon the above-mentioned
pr er or in ion purposes
IAn ' , I SEE REVERSE FOR EXPLANATORY LANGUAGE.
net of Pe IttAd �"' - C'JS .
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 - - �EL•ECTRICAL-PERMIT
DEPARTMENT OF PUBLIC WORKS 9071 LAS TUNAS EL,0508-9805140059
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA
PHONE: (818) 285-0488 EXT:
LEGAL ID: FEES PAIDUIL I NG-ADDRE_S_S_: -
TR: 11218 LT: 5 BL: A 9028-BROADWAY. }
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917802310
ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET: ROSEMEAD
5388-003-006 Al PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 596 GRID: H4 LOCALITY: TEMPLE CITY
G1 OUTLETS-LGT,SW,RECP 8.00 OUT 15.60 1
TENANT: G2 LIGHTING FIXTURES 1.00 LGT 1.95 SSUEO ON: PROC SSED BY: A BY: EXP RES ON:
H7 RES EXHAUST FANS 1.00 EX 10.80 05/15/98 UT 05/15/99
TOTAL FEES 56.10
OWNER: TEL. NO: FINAL DATE FINAL B - CODE:
PENG, ERIC (213) 722-9123-
9028 BROADWAY
TEMP 917802310 DESCRIPTION OF WORK
ELECTR I CAL'FOR-NEW-BEDROOM-ADDU ION-
APPLICANT:
N- ?
APP CAN -TFL. NO:
MASTER DESIGN CONSTRUCTION, INC. (626) 447-2228-
60 E. LAS FLORES AVE SPECIAL CONDITIONS:
ARCADIA, CA
O P�IGELES CO
CONTRACTOR: TEL. NO: U�T APPROVALS DATE INSPECTOR SIGNATURE
5
MASTER DESIGN CONSTRUCTION INC. (626) 447-2228- V y
60 E. LAS FLORES AVE LIC. NO TEMPORARY POWER POLE
ARCADIA,CA 91006 592011 C36
UNDERGROUND-CONDUIT-
ARCHITECT
ONDUITARC T OR ENGINEER: TEL. 0: UFER GROUND
LIC. NO: I SIF- 1111111 ROUGH CONDU-IT --
ROUGH WIRI G
7�� MAIN WATER LINE
1 / I 1 PLASTIC Y/N METAL Y/N
-- - - -- - -% TIT MY COMPANY OT I FI ED
„ice
REPORT ID: DPR265 ROUTE TO: BS0508
COUNTY OF LOS ANGELES TEMPLE CITY # 0508ELECTRICAL PERMIT_ _ {
DEPARTMENT OF PUBLIC WORKS 9071 LAS TUNAS EL70508-9807160017
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA
PHONE: (818) 285-0488 EXT:
LEGAL ID: FEES PAID BU LDING-ADDRESS:-
TR: 11218 LT: 5 BL: A �9028_BROADWAY--
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917802310
ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET: ROSEMEAD
5388-003-006 Al PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 596 GRID: H4 LOCALITY: TEMPLE CITY
G1 OUTLETS-LGT,SW,RECP 6.00 OUT 11.70
TENANT: G2 LIGHTING FIXTURES 5.00 LGT 9.75 ISSUED ON: PROCESSED BY: PLAN BY: EXPIRES ON:
TOTAL FEES 49.20 07/16/98 UT 07/16/99
OWNER: TEL. NO: FINAL DATE FIN Y: CODE:
PENG, ERIC (213) 722-9123-
9028 BROADWAY
TEMP 917802310 DESCRIPOf- -
(
ADDITION-PER-FOR-EXTRA.OUTLE AND-LIGHTS-FOR-ADDITION 1
APPLICANT: TEL. NO:
SAME AS OWNER -
^`-�.. SPECIAL CONDITIONS:
i�GEGE
LES 0-
(/!
CONTRACTOR: TEL. NO: O vT� APPROVALS DATE INSPECTOR SIGNATURE
SAME AS OWNER -
LIC. NO 4 TEMPORARY OW POLE
J �ARCHITECTOR ENGINEER: UNDERGROUND CONDUIT TEL. N0: / �1I J(r�� ' ,/ LIFER GROUND
LIC. NO!I� ROUGH CONDUIT
ROUGH WIRING
"��� 'i�,U-��, ii/ice \h•��I���I'J�� /(/ �� MAIN WATER LINE
PLASTIC Y/N METAL Y/N
UTILITY COMPANY NOTIFIED
`F:
�S.vice
REPORT ID: DPR265 ROUTE TO: BS0508