HomeMy Public PortalAbout5738 CAMELLIA AVE_Electrical__ WORKER'S COMPENSATION DECLARATION 20-0019 DPW(,2-G1) APPLICATION FOR ELECTRICAL PERMIT
I herebyby affirm that I have a certificate of consent to self Insure, 7tlABB3 ,
or a certlflcate of Worker's Compensatlon Insu co, or a certified COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV.
dopy thereof(Sec.480W Lab.C.)
Poilcy No. Foe AppocA fr To r9_L N Joe
. - .. ADDRESS
Certtw co,y lezd
"'had. New Reeidentlgl Bldgs.h Poole NO. EACH FEE LOCALITY
o09ycounty Wkfing Inspection 1 ✓4 2-FamRy,Sq.Ft _ $ = N ET C
❑. CertfM1ed ith the
Multl-tem Ry Sq.Ft- CRO86 ST.
Data App4cort Reskiential Swtmminq Pooh A88ESSOR
1 NAP SoOK PA(lE PARCB_
C1 1`1GATE OF b�EMPTK>N FROM WORKERS' Outietd:P.. + Light—�—Sw. MER OFl
COMPENSATION INSURANCE db F1 Rye
(This section need not be complete if the work Involved by the Rroi AO 88
permit to for one hdndred dollars($1.00)or Fees.) Total No. Add�tlonal I►1��'
I oertlfy that'In the perforrnance•of the work for whrch this permit. CITY TeL No
Is leeubd, I shall not employ any person In tiny manner so as to PLAN CHECK
becorpe subject to the Workers' Compen n Lawe. Lighting Fixtures First 20 2 AAPUCANT
Total No Addhkmal ADDRESS
Date APPI RE84DENTLILL APPLIANCES NOT.OVER 3 HP.
NOTI ,TO. PPj,ICANT: If, after m ng thle Certlflcate of CITY Tei.No. '
Exemption,you should become subject to the Workers'Compensatlon OTHER APPLIANCES NOT OVER 3 HP.
provlelons of the Labor Code, you must forthwith comply with suchUG�xT
provisions or thF4 permlt shall be deemed revokeq. Power Apparatus S Large Appllarwse
t"• LUENSED CONTRACTORS DECLARATION Size✓4 Type HP,KW,KVA,or KVAR' ADDRE
I'hefeby affirm that I am Iloensed under provlsfone of Chapter 9Over 3 to 10 Ind.
(oommenoing wlth Section 7000) of Dlvlelon 3 of the Business and Tei No.
Profeaslons Code,and my Iloeneo Is In full force and effect. Over 10 to 60 Ir4. I }
Over 60 to 100 Ind. RUM-BEA C� �7 d
1 Over 100
Lberrae Number '7 7/ Z O Llc.Class� 117
'��.,MCC S RanNbosrds oteTRtCT No.,os PROCE av � f
Sw0cee
l� 0-390 Amp.Under PATE 5
❑ I em exempt under Sec 400-,000 Amp.Under �- * yA11DAT1o11 w
over,000 Amp.or over 600 V F NAL D
B.SP.C.for this meson Z
BRANCH CIRCUIT FEES
Data: 161 or 20A,120V,LJghdW or Recept
1 To 10 Branch Clroufts
Signature 11 To 40 Branch ChuO
F-141 Or More Branch Clrculls
Exemption for Rag.MahrL EacL 161 201 20BV To EW Lgaq Br.
SINGLE FAMILY Temp,PowAr Pole S Appurtenances 2 '
HOME OWNER-BUILDER D TION $1gn with One Branch Clrouft ACCT■r
I hereby affirm that I am exempt from Contractor's I-Unse Law pf1
for the following reason (Section 7 .6, Buslneas and Profeealons Addltonal Sign Branch Clrcults 3303 113.7tr
Code): .7�,7 i C +
❑ I,as own ar of the will do the work and the structure MIoo.Conduits A Conductora w11 IT[iJ t,7i
Is not Intbnded offered for ea-le (Seotlon 7044, Business Other(See Compote Fee Schedule) , TOTAL 1 13 .90
and Profess! Code}. i ice.
90
NSTRUCTION No AGENCY W
I hereaffirm by arm that there is wCHAWE ■netotlon lending agency for the W
00
performance of the work whfch this permit Is Issued (Sec. 3097, PERMIT FEE (Sub-Total)
Civ.C.)
PLAN CHECKING FEE 000D-0W1 1/30/96
Lenders Narrw PERMIT ISSUING FEF 4562 1 AM10E06
Lsndere TOTAL FEE
I oertfry I have reed this eppOceifon and under penalty of perjury etsde
the the above Informcdbn Is oorrecL I agree to corrpty with all County
ordnanoes and State taws regulating EFectrfcal wiring,and hereby authortze
of this County to enter upon the above-m�property
Pu SEE REVERSE FOR EULANATORY LANGUAGE
Af(o11111I 5f FIE� 4
DATE
COUNTY OF L0S ANGELES TEMPLE CITY 4 0508 ELECTRICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS EL 0508 0903240024
BUILDING AND SAFETY / LAND DEVELOPMENT TEGgE CITY CA 91780
PHONE: (626) 285-0488 ETT:
LEGAL ID: FEES PAI BUILDING ADDRESS:
TR: 6561 LT: 547 5738 CAM]=• Ia AV
FEE DESCRIPTION: QUANTITY: Uom; AMOUNT: TEMP CA 917802501
ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET:
8587-022-020 Al PERMIT ISSUANCE FEE 27.75 TfCIHAS PAGE: 597 GRID: A3 LOCALITY: TEMPLE CPI'Y, C
O1 OUTLETS-L(3T,SW,RECD 4.00 OUT 7.80
TENANT: G2 LIGH'T'ING FIXTURES 5.00 IAT 9.75 ISSUED ON: PROCESSED BY: PLAN BY: EZPIRFi9 ON:
TOTAL FEES 45.30 03/24/09 SR 09/20/09
OWNER: TEL. NO: F DATE FINAL Y: CODE:
CZ-ANG/WANG, VICCKY/NICU (626) 589-9689-
5738 CAMELLIA AV
TE14P 917802501 DESCRIPTIC4 OF WORK
EIRC RTC7iL FOR NEN ADDITION
APPLICANT: TEL. NO:
NTUYEN (626) 674-3014- '
1139 GI,ENVIE'W ROAD SPECIAL CONDITIONS:
WEST COVINA CA
CONTRA=R: TSL. NO: APPROVALS DATE INSPECTOR SIGNM, URE
WANG, NICK (626) 589-9689-
5738 CAMEIJ A AVENUE LIC. NO TEMPORARY POWER POLE
TEMPLE CITY, CA 91780 NONE
U DERGROUND CONDUIT
ARCHITECT OR E4GIMER: TEL. NO: LIFER GROUND
LIC. 190: ROUGH CONDUIT
ROUGH WIRING
MAIN IQLTER LI2PE
PLASTIC YIN )E-fAT. YIN
9=1TY COMPANY NOTIFIED
a•
RE-PORT ID: DPR265 ROUTE TO: BS0508
COUNTY OF LOS ANGELES TEMPLE CITY k 0508 ELECTRICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS EL 0508 0806180022
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 ETT:
LEGAL ID: FEES PAID BUILDING ADDRESS:
TR: 6561 LT: 547 5738 CAMELLIA AV
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917802501
ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET: LIVE OAL
8587-012-020_ _ Al PERMIT ISSUANCE FRE 27.75 T%OMAS PAGE: 597 GRID: A3 LACALITY: TEMPLE CTTY, C
G1 OLTPL-rS-LGT,SW,RSCP 6.00 OUT 11.70
TENANT: G2 LIGHTING FIXTURES 8.00 LOT 15.60 ISSUED ON: PROCESSED BY: PLAN BY: EXPIRES ON:
H2 RES GRBG DISP LT 3HP 1.00 DIS 10.95 07/14/08 9R 01/10/09
H3 RES DISHIA314R LT 3HP 1.00 DIS 10.95
DESERT
6) NO: TOTAL FRES 76.95 FSN1+L'Il^AT FIHj+L_BY: CODE:
DESERT Q PACIFIC ENTERPRISE (626) 251-3517- •��l"-�`rl,-(-}I� ��/`1(Y\1
914 E. SERVICE AVE kfT
WEST COVINA CA 91790 DESCRIPTION OF WORK i
ELE=CAL FOR ADDITION AND REMODEL
APPLICANT: TEL. NO:
DESERT R PACIFIC ENTiiRFRI.4R (626) 251-3517-
914 E. SERVICE AVE SPECIAL CONDITIONS:
WEST COVINA CA 91790
CON-TRACTOR: TEL. NO: APPROVALS DATE INSPECTOR SIGNATURE
MARX XIIJ.IAMS (626) 251-3517-
914 E. SERVICE AVE OB L,IC. NO TE Y POWER POLE
WEST COVINA, CA 91790 NONE
UNDERGROUND CONDUIT
ARCHITECT OR ENGINEER: TEL. NO: U= GROUND
LSC. NO: ROUGH ODIC=
ROUGH WIRING
MAIN WATER L 2iE
PIABTIC YIN METAL YIN
UTILITY COMPANY NOTIFIED
REPORT ID: DPR265 ROUTE TO: B90508