HomeMy Public PortalAbout5802 GOLDEN WEST AVE_Electrical__ WORKER'S COMPENSATION DECLARATION 720-0019 6A663 DPW(12-91) APPLICATION FOR ELECTRICAL PERMIT ,u
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. 6F PUBLIC WORKS BUILDING AND SAFETY DIV
copy thereof(Sec 3800 Lab C)
Policy No Company FOR APPLICANT TO FILL IN JOB -
ADDRESS
SCertrfled copy IS hereby furnished New Residential Bldgs &Pools NO EACH FEE
$ $ LOCALITY
❑•, Certified copy Is filed with the county building Inspection 1 &2-Family,Sq Ft NEAREST
department Multi-family Sq Ft CROSS ST
Date Applicant 2 Residential Swimming Pools ASSESSOR -
MAP BOOK PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets Rec —Light Sw OWNFIRM R OR
COMPENSATION INSURANCE s _
First 20 MAIL -
(This'section need not be completed If the work Involved by,the Total No Additional ' !ADDRESS
permit Is for one hundred dollars($100)or less.) r"
I certify that in'the performance of the work for which'this permit CITY
is issued, I shall not employ any person in any manner so as to PLAN CHECK
become subject to the Workers' Compensation Laws Lighting Fixtures First 20 APPLICANT
Total No Additional
�- �/ 'T7
ADDRESS
Date Applicant ( C_L1�CTT RESIDENTIAL APPLIANCES NOT OVER 3 HP
NOTIC O A PLI ANT If, after making 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
provisions 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 70 00) 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 }
Over 50 to 100 Incl LICENSE Class
REG NUMBER d
Over 100 DISTRICT NO CESSED BY O
License Number Lic Class 0
cis Swbd CPa FINAL
Contractor Date, 9 Amp U e 00 V DATE O
❑ am exempt under Sec 400-1000 Amp Under 600 V �2 W
I
Over 1000 Amp or Over 600 V FINAL VALIDATION
d
B&P C for this reason BRANCH CIRCUIT FEES BY U)
Date 15A,or 20A, 120V,Lighting or Recept AA Z
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 y i
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License Law
for the following reason (Section 7031 5, Business and Professions Additional Sign Branch Circuits `q
Code) i,
ElE'`I'•1 -
I, as owner of the property, will do the work and the structure Mlsc'Conduits&Conductors 1 IT
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) g 01 PL 63 - 45
and Professions Code) _
�^ r:•9
CONSTRUCTION LENDING AGENCY
I 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
Lender's Name
PERMIT ISSUING FEE' �lQ d 255 1 FN Lr= t+?
Lender's Address
I certify that I have read this application and under penalty of purlury state, TOTAL FEE 3
that the 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 SEE REVERSE FOR EXPLANATORY LANGUAGE
At
eAGNAlUXEAMITTEE19
DATE
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 ELECTRICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS EL 0508 9905040012
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
EGA FEES PAID BUILDING DDR SS:
TR: 6561 LT: 453 5802 GOLDEN WEST AV
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917802203
ASSESSOR INFORMATION BER: NEAREST CROSS STREET:
8587-027-026 Al PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 597 GRID: A3 LOCALITY: TEMPLE CITY, C
HA FAU LESS 3HP 1.00 FAU 10.80
TENANT: JB AC UNITS +3-1OHP 1.00 AC 19.80 ISSUED ON: PROCESS : P ON:
TOTAL FEES 58.35 05/04/99 VG 10/31/99
OWNER: TEL. NO: FINAL DATE FINAL BY CODE:
CICCHETTI CARL (626) 287-0757- --y (�
5802 GOLDEN WEST AV J
TEMP 917802203 —DE-s-c-RTF-TION OF WORK
ELECTRICAL FOR HEATING AND COOLING
APPLICANT: TEL. NO:
AMERICAN HEATING & AIR CONDITIONING (626) 285-8206-
SPECIAL CONDITIONS:
Ili I ES Co
CONTRACTOR: TE 0: ® APPROVALS DATE INSPECTOR SIGNATURE
AMERICAN HEATING AND AIR (626) 285-8206-
5422 N MUSCATEL AVE LIC. NO TEMPORARY POWER POLE
SAN GABRIEL CA 91776 664929 C2O
/ UNDERGROUND CONDUIT
CHI 0 TE FER GROUND
LIC. N0: 1111111
ROUGH CONDUI
T
OG WIRING
PLIN ITER LINE
Rv��JASTCY/N
METAL Y/N
J J L O t
I�. NOTIFIED
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Service Yha�
REPORT ID: DPR265 ROUTE TO: BSO5O8