HomeMy Public PortalAbout5221 DOREEN AVE_Electrical__ WORKFRS'GOMPENSATIONDECLARAT[ON 63
CE 8O6G (280) APPLICATION FOR ELECTRICAL PERMIT {�
CElJI hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY
insure, or a certificate of Workers'Compensation Insurance,or T C '0,
a certified copy thereof(Sec. 35 0, Lab.C.)
(/Policy �L� Lrr�(jQf� nn S ff� Y I FOR APPLICANT TO FILL IN AD � I �/No. •/ Companyf�L7 ` 1T EACH NO. FEE ADDRESS / /V.
New Residential Bldgs.& Pools
® Certified copy is hereby furnished. 1 &2-Family,Sq. Ft. $ $ LOCALITY )
❑ le-
Multi-family Sq, Ft. EAREST
Certified copy is filed with the county building inspection CROSS ST
\ department. Residential Swimming Pools OWNER OR
(( ��������QQ�� / �/,�� r FIRM NAME I('
DateG/{pplicant /� �,�C�£� �•"'r-r" �utlets: RecJ�Light See �j�1 ADDRESS
First 20
CERTIFICATE OF EXEMPTION FROM WORKERS' Total No._� Additional CITY Tel No.
COMPENSATION INSURANCE }
PLAN CHECK tl
APPLICANT O
(This section need not be completed if the work involved U
by the permit is for one hundred dollars (SIOO) or less.) Lighting Fixtures First 20 ADDRESS
Total No. Additional O
I certify that in the performance of the work for which this Fixed Appliances Not Over 1 HP CITY Tel No.
permit is issued, I shall not employ any person in any manner PERMIT /' 1 W
so as to become subject to the Workers' Compensation Laws. Range_Heater_O.W. APPLICANT W � d
Oven _ Dryer ✓W.M. ADDRESS r Z
Date Applicant Top — FAU _W.H.. - % r n -
Hood _ Fan —Other_ CITY i.-.�aT I No.A _ M
NOTICE TO APPLICANT: If, after making this Certificate of Disp. — Room Air Cond._ 3,00 LICENSE OR 1
Exemption, you should become subject to the Workers' REG. NUMBER Class C-/Q
Compensation provisions of the Labor Code, you must forth- Power Apparatus& Large Appliances DISTRICT NO. PROLEED BY
with comply with such provisions or this permit shall be pi
deemed revoked. Size&Type HP, KW, KVA•or KVAR 6-
Up to 1 Incl. "
Over 1 to 10 Ind. FINALDATE 6-3 -�2 VALIDATION
LICENSED CONTRACTORS DECLARATION Over 10 to 50 Incl.
I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. FINAL
9 (commencing with Section 7000) of Division 3 of the Busi- Over 100 BY eJ l�L
ness and Professions Code, and my license is in full force.and t
effect. q /7 n Services -
License Num-¢fr 3(o /Lic. Class `' -I L) 0-200 Amp. Under 600 V ,
CL
V 201-1000 Amp. Under 600 V QO
Contractor -P hP; IPGDate (O J '�/Z - Over 1000 Amp.or Over 600 V J II
HOME OWNER-BUILDER DECLARATION Temp.Power Pole& Appurtenances ,
I hereby affirm that I am exempt from the Contractor's Sign with One Branch Circuit
License Law for the following reason (Section 7031.5, Busi- Additional Sign Branch Circuits
ness and Professions Code):
Misc. Conduits&Conductors 4 1 9.3 A
Fit. as owner of the property, will do the work and the Other (See Complete Fee Schedule)—
structure is not intended or offered for sale (Section )!f e,a o 0 . 2
7044, Business and Professions Code). '
CONSTRUCTION LENDING AGENCY 2.^.� 3 Q, �� Q
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is PERMIT FEE (Sub-Total) ol
e-o0 3 Q• ), Q
issued (Sec. 3097,Civ.C.).
Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee) 01602-82
Lender's Address PERMIT ISSUING FEE �/ L
1 certify that 1 have read this application and state that the TOTAL FEE 3 C-) U
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 purposes. SEP REVERSE FOR EXPLANATORY LANGUAGE
ignat ure of Permittee Dale ,
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 ELECTRICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS _ EL OSOB 0609060007
BUILDING AND SAFETY'/ LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
LEGAL ID: FEES PAID BUILDING ADDRESS:
IN: 11290 LT: 23 BL: C 5221 DOREEN AV
PEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917803441 ,
ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET:
8585-023-038 Al PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 597 GRID: C4 LOCALITY: TEMPLE CITY, C
G1 OUTLETS-LGT,SW,RECP 28.00 OUT 49.80
TENANT: G2 LIGHTING FIXTURES 10.00 LGT 19.50 ISSUED ON: PROCESSED BY: PLAN BY: EXPIRES ON:
HA PAU LESS 32P 1.00 FAU 10.95 10/05/06 JK 04/03/07
JB AC UNITS +3-10HP 1.00 AC 19.65
OWNER: TEL. N0: LA 100 AMP PANELS, MCC 1.00 PAN 38.85 �A�DATE FINIy BY: CODE:
5221 SU HONG (626 318-5799- TOTAL PEES 166.50 7 �-,y
5221 DOREEN917803 AV
TEMP 91]803941 D SCRIP ION F '
ELECTRICAL FOR ADDITION AN UPGRADE SERVICE TO 100 AMP
APPLICANT: TEL. NO:
ZHU (626) 318-5799-
5221 DOREEN AVE SPSCIAlL� CONDITIONS:
TEMPLE CITY CA 91700 �111C APPROVALS
CONTRACTOR: TEL. NO: DATE INSPECT SIGNATUR
H D CONSTRUCTION (626) 695-0444-
4418 FANDON AVENUE LIC. NO TEMPORARY POWER POLE
EL MONTE, CA 91732 636105 B '
' UNDERGROUND CONDUIT
ARCHITECT OR ENGINEER: TEL. NO: UPER GROUND
LIC. NO: ROUGH CONDUIT
ROUGH WIRING
MAIN WATER LINE
PLASTIC YIN METAL YIN
UTILITY COMPANY NOTIFIED
' ADDITIONAL DATA ON FILE
REPORT ID: DPR265 ROUTE TO: BS0508