HomeMy Public PortalAbout4541 CLOVERLY AVE_Electrical__ WORKER'S COMPENSATION DECLARATION+ 76A663_. 9 DPW(12-91) APPLICATION FOR ELECTRICAL PERMIT
76A66
I hereby affirm-that rhave 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 JOB4-941 �'�
ADDRESSny Ave , C.
Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE
$ $ LOCALITY
El , Certified copy is filed with the county building inspection 1 &2-Family,Sq.Ft. _ NEAREST
department. Multi-family Sq. Ft. CROSS ST
LAwoLowen
Date Applicant Residential Swimming Pools ASSESSOR
MAP BOOK PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' J OWNER OR
COMPENSATION INSURANCE Outlets:Rec._Light 3 Sov.�_ Z �! FIRM NAME
m!
ryry First 20 �O MAIL
(This section need not be completed if the work involved by the Total No.�_ Additional 7 "1— ADDRESS 1 IC
Var_LV
permit is forone hundred dollars($100)or less.)
I certify that in the performance of the work for which this permit CITYTepus—
CAq Tel.N 4
is issued, I shall not employ any person in any manner so as to PLAN CHECK "t[
become subject to the Workers' Compensation Laws. Lighting Fixtures First 20 APPLICANT
�yp Total No.—S Additional ADDRESS
Date 4 Applicant &4A11JC{L 60'0//V L RESID ALA PL CES 0 OV 3 HP. ,
NOTICE TO APPLICANT: If, after raking this Certificate of CITY Tel.No.
Exemption,you should become subject to the Workers' Compensation OTHER APPLIANCES NOT OVER 3 HP.
provisions of the Labor Code, you must forthwith comply with such PERMIT /1
provisions O
or this permit shall be deemed revoked. Power Apparatus&Large Appliances APPLICANT
LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS
I hereby affirm that I am licensed under provisions of Chapter 9 Over 3 to 10 Incl.
(commencing with Section 7000) of Division 3 of the Business and CITY Tel.No. '
Professions Code, and my license is in full force and effect. Over 10 to 50 Incl. >_LICENSE Class.
Over 50 t0 100 Incl. REG.NUMBB ER CL
Over 100 DISTRICT NO. P�, D B O
License Number Lic.Class ,� O� Q
Services,Swbd.,MCC&P elboards
/ 9 "Amp Under 600 V 600 V 4/ 7" FINAL L
Contractor Date DAT O
F-1 /400-1000 A Under "qj VALIDATION U
I am exempt under Sec. W
Over 1000 Amp.or Over 600 V FINAL
B.&P.C.for this reason BRANCH CIRCUIT FEES y� BY Z
Date: fl15A,or 20A,120V,Lighting or Recept. °7 Jl�>
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
HOME OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits
Code):
.........._. •�
F-1 1, as owner of the property,will do the work and the structure Misc.Conduits&Conductors AC(6•i°1x
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) s 1
°i
and Professions Code). lug
t 1
•I T
CONSTRUCTION LENDING AGENCY ITEMS-)
I
I hereby affirm that there is a construction lending agency for the i=1Tf4t - 15
performance of the work for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total) Lt rG - -- q
Civ. C.) i lY` CHECK 1 _t°15
PLAN CHECKING FEE �I
Lender's Name CHANGE 0A
PERMIT ISSUING FEE
Lender's Address r^
1 certify that I have read this application and under penalty of purjury state TOTAL FEE g�, SLI— (; 4 41/
that the above information is correct. I agree to comply with all County 1 i {M ry°
ordinances and State laws regulating Electrical wiring,and hereby authorize ,3L 1 f A F ; °_c
t.,
representatives of this County to enter upon the above-mentioned property
or inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Y--:27- 9 3
SIG TURE OF PERMF17EE DATE
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 ELECTRICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS EL 0508 0203260025
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
LEGAL ID: FEES PAID BUILDING-ADDRESS:
TR: 12998 LT: 4 4541 CLOVERLY AV
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917804204
ASSESSOR INFORMATIO NUMBER: NEAREST CROSS STREET: LOWER AZUSA
8592-003-026 Al PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 597 . GRID: A5 LOCALITY: TEMPLE CITY
G1 OUTLETS-LGT,SW,RECP 28.00 OUT 49.80
TENANT: G2 LIGHTING FIXTURES 13.00 LGT 25.35 ISSUED ON: PROCESS BY: PL EXPIRES ON:
H7 RES EXHAUST FANS 2.00 EX 21.90 03/28/02 JK 09/24/02
TOTAL FEES 124.80
OWNER: TEL. NO: FINAL DATE FINAL BY: CODE:
WONG;SAMMY (626) 673-8103-
4541 CLOVERLY t-j4-�— S o
TEMPLE CITY 91780 DESCRIPTION OF WORK
ELECTRICAL FOR ADDITION
APPLICANT: TEL. NO:
SAME AS OWNER -
SPECIAL CONDITIONS:
CONTRACTOR:
TEL. NO: - ��� C9J�� APPROVALS DATE INSPECTOR SIGNATURE
SAME AOWNER
LIC. NO TEMPORARY POWER POLE
i UNDERGROUND CONDUIT
ARCHITECT OR ENGINEER: TEL. NO: - � �! UFER GROUND
LIC. NO: _ �� ` 1111111 1 ROUGH CONDUIT
�I l
ROUGH WIRING Q
Fi �f� ���� �� P MAIN WATER LINE
I �LF � I PLASTIC Y/N METAL Y/N
UTILITY COMPANY NOTIFIED
(epe.a9 �(a
REPORT ID: DPR265 ROUTE TO: BS0508