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HomeMy Public PortalAbout9821 DAINES DR_Electrical__ •i / J , WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12-97) 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 fhereof,_(Sec. 3800 Lab. C.) - JOB `i Policy No. Company �w` �' FOR APPLICANT TO FILL IN' ADDRESS to 21- ❑ ` � -copy y' New Residential Bldgs.&Pools NO. EACH FEE Certified co s Fiereb furnished. 9 _ $ $ LOCALITk j Certified copy is filed with the county building' pection 1 &2-Family,Sq.,Ft. _ NEAREST department. Multi-family Sq..Ft. CROSS ST. Date 2 1 2- Applicsn Residential Swimming Pools ASSESSOR q p / MAP BOOK PAGE © @, PARCEL C13 CERTIFICATE OF EXEMPTION FRO RS'' t` 10 _ OWNER OR COMPENSATION INSURANCE. Outlets:Rec. Ligh Sw. 7 FIRM NAME ! ..t'-. + First 20 /� C� MAIL . (This;section need not be completed If the work Involved by the l permit Is for one hundred dollars(5100)or less.) Total No. Additional ADDRESS 2 � `I �j I certify that in the-performance,of'the-Work for which this permit f CITY Tel.No. is issued, I shall not employ any person in.any manner so as to y j 7� 161 become subject,to the Workers' Compensation Laws. Lightirig Fixtures First 20 v PLAN p APPLICANT - - �, -Total No.�" Additional ADDRESS Date. Applicant'-- RESIDENTIAL'APPLIANCES NOT OVER 3. . NOTICE TO. APPLICANT: if, atter making this:Certificate of HP / CITY Tel.No. Exemption,.y,ou 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 proJisions or this-permit'shall be deemed revoked. Power Apparatus&Large Appliances APPLICANT LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS`�2 I hereby,'affirm-that 1 am licensed under provisions of Chapter 9 ry�Over 3 to 10 Incl. d (commencing with Section 7000)-of Division 3,of the Business and, CITY� G �L " BOA Tel No. !t,­93 S-_ Professions Code;and my license is in.full force and effect. Over 10 to 50 Incl. } LICENSE ORn �--1 Class. Over 50 t0 100 Incl. 'REG.NUMBER�j �L� r'�✓ ,. 1_3 O License Number���2 Lic.Class Over 100 - DISTRICT NO. -. R SSED BY U Y Services,Swbd.,MCC&Par��Iboardp� �® Cc Contractor y Date �/ —/�L 0-399 mp. nder 600 r/ _DATE O ❑' I am exempt under Sec. 400-1000 Amp.Under 600 V �2'��7/�3 0 Over 1000 Amp.,or Over 600 V FINAL ` VALIDATION B.&P.C.for this reason - BRANCH CIRCUIT FEES BY 9 Z Date: 15A,or 20A, 120V,Lighting or Recept. r _ 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 A a HOME OWNER-BUILDER DECLARATION rcuif ACCT. . I hereby:affirm Sign with One Branch'Ci that I am exempt from the Contractor's License Law .. � 123.021, ` '. for the following reason (Section 7031.5, Business and Professions Additional SigWBranch Circuits {yyaQsu 3307 Code): �{ _ ❑ y .1 ITEMS I,as owner of the property,will do.the work.and the structure Misc.Conduits&Conductors A" '"'' y.wp g is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) x.,,. ,� TOTAL and Professions Code). CONSTRUCTION LENDING AGENCY C14ECK~ _ .123, 2. L F .. I.hereby affirm that there iGHAEs a construction,lending agency for the - - �-�-'- '• _ .. - OCI _ performance-of the work for which this permit is issued (Sec. 3097; PERMIT FEE (Sub-Total) Civ. C;) Fut a PLAN CHECKING FEE' Ct[tC�il�—tivu -17f -2/92 Lender's Name tk . PERMIT ISSUING FEE .. ._: a,.••:. 6736 AC�il!_?J Lender's Address I certify that I have read this application and under penalty of purjury state TOTAL FEE /a Oa that the above information is correct. I agree to comply with all County ordinances and State laws regulating ectrical wiring,and hereby authorize representatives of this County.to e e upon the above-mentioned property for inspection purposes. SEE REVERSE'FOR EXPLANATORY LANGUAGE• S NAT,URE•OF PERMITTEE DATE - - COUNTY OF LOS ANGELES TEMPLE .CITY # 0508 _ ELECTRICAL PERMIT - DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS EL 0508 1204180044 ' BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 . ._ PHONE: (626) 285-0488 EXT: . (LEGAL ID: I FEES PAID '1- BUILDING ADDRESS: ITR: 13805 LT: 64 _ I - I 9821 DAINES DR - I IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT:( TEMP CA 917802637 - 1 (ASSESSOR INFORMATION NUMBER: 1 - -1 NEAREST CROSS STREET: BALDWIN-,, I 18588-016-039 - - - IA1 PERMIT ISSUANCE FEE 27.80 THOMAS PAGE: 59.7 GRID: A3 LOCALITY: TEMPLE CITY, Cl I IF1 120V, 15/20A BR CKTS 1.00. BR 17.30 (TENANT: IG1 OUTLETS-LGT,SW;RECP -- 3.00 OUT 6.00 JISSUED ON: PROCESSED BY: PLAN BY: 1 I 1G2 LIGHTING FIXTURES 6.00 LGT 12.00 104/18/12 "+ SR- I I I TOTAL FEES 63.10 1 - �_ __ I TOWNER: TEL. NO: i (FINAL DAT ��rI _ INpALIgBY: CODE: . -i CONWAY JOHN,F;VIRGINLA D (626) 286-3913- -p p 19821 DAINES DR I 1 IFmll ddd"' S - (TEMP 917802637 - I .IDESCRIPTION OF WORK I I 11 BRANCH CIRCUIT, 3 OUTLETS AND 6 .LIGHT FIXTURES" 1 (APPLICANT: - _ TEL. NO: I -- - � ITSAI, WILLY (626) 281-5726- I .•I I I I .1SPECIAL CONDITIONS: 1 1CONTRACTOR-: TEL. NO: 1 JAPPROVALS DATE INSPECTOR SIGNATURE IPARTAIN'CONSTRUCTION (626) 281-5726- 1326 BELLA VISTA LIC. NO .. - ITEMPORARY POWER POLE I IMONROVIA, CA 91016 - 950949 B I - 1 - I ( (UNDERGROUND CONDUIT (ARCHITECT OR ENGINEER:. TEL. NO: I IUFER GROUND I I I ITSAI, WILLY (626) 281-5726- 1 - II ' I I 1236 S ATLANTIC BLVD - LIC. NO! I _ _ ." • _ - IROUGH CONDUIT I I I 1ALHAMBRA CA 91803 - • 950949 B I I I" I - I 1 I (ROUGH WIRING -4 1.1' 1 I i IMAIN WATER LINE I I IPLASTIC YIN, METAL YIN I 1 I I (UTILITY COMPANY NOTIFIEDI I 1 I .I 1 1 1 I• .• ' I 1 I I I _• 'I I 1 _ I I• ADDITIONAL DATA ON FILE " " - (REPORT ID: DPR265- .,ROUTE TO: BS0508 I I I I