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HomeMy Public PortalAbout5939 GOLDEN WEST AVE_Electrical__ WORKERS'COMPENSATIONDECLARATION CE-806G (2-80) APPLICATION FOR ELECTRICAL PERMIT K If-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 / a certified copy thereof(Sec, 3800,Lab. C.) FOR APPLICANT TO FILL IN SOB Policy No �ereykVshqc[C EACH NO. FEE ADDRESS Golden West AyI ,n rh New Resident) Bldgs.&Pools pCert fe co is �� 1 &2-Famil Sq. Ft. $ — $ LOCALITYTe1n le City ❑ Multi-family Sq. Ft. — NEAREST Certified copy is filed with the county building inspection CROSS ST department. Residential Swimming Pools OWNER OR FIRM NAME City of Temple City Date Applicant Outlets: Rech Light Sw. L MAIL p First 20 ADDRESS 5938 No Kauffman Avenue CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. Additional CITY Temple City. Tel No28 _2l 1 COMPENSATION INSURANCE >- PLAN CHECK tl (This section need not be completed if the work involved APPLICANT 0 by the permit is for one hundred dollars ($100 or less.) Lighting Fixtures / First 20 ADDRESS U Total No. Additional I certify that in the performance of the work for which thisCITY Tel No. 0 Fixed Appliances Not Over 1 HP. permit is issued, I shall not employ any person in any manner PERMIT U so as to become subject to the Workers' Compen�tin s. Range_ Heater_D.W. APPLICANT C W o ( Oven _ Dryer_W.M. ADDRESS ''1 ( / r� /� P Z Date tAprplicant .��� Top _ FAU _W.H.,_ V �I� _ Hood — Fan _Other_ CITY ��!� �Z (2,(C Tel No. �— 1 NOTICE TO APPLICAN after making this Certificate of Disp. — Room Air Cond._ LICENSE OR / © Exemption, you shou d ecome subject to the Workers' REG.NUMBS '� Class �! Compensation provisiois of the Labor Code, you must forth- Power Apparatus& Large Appliances DISTRICT NO. PROCESSED BY with comply with such provisions or this permit shall be Size&Type HP,KW, KVA,or KVA deemed revoked. Fi `f Up to 1 Incl. JINAL Over 1 to 10 Incl. ATE/LICENSED CONTRACTORS DECLARATION tVALIDATION Over 10 to 50 Incl. I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. r 9 (commencing with Section 7000 of Division 3 of the Busi- BY ( g ) Over 100 ness and Professions,Code, and my license is in full force and effect. / Services License Numbe Q 6 Sy Lic.Class b 0-200 Amp. Under 600 V 201-1000 Amp. Under 600 V Contractor Date _ v / Over 1000 Amp.or Over 600 V HOME OWNER-BUILDER DECLARATION Temp. Power Pole&Appurtenances I hereby affirm that I am exempt from the Contractor's Sign with One Branch Circuit Additional Sign Branch Circuits License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): Misc.Conduits&Conductors ❑ I, as owner of the property, will do the work and the Other (See Complete Fee Schedule)— 4 2 3 3 A structure is not intended or offered for sale (Section 7044, Business and Professions Code). 4 0 0 o o 88 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency 0,0 C 0•0 0 0 z for the performance of the work for which this permit is PERMIT FEE (Sub-Total) issued (Sec. 3097,Civ.C.). 0 -7,07-8 1 Lender's Name PLAN CHECKINGTEE (One-Fourth Permit Fee) Lender's Address PERMIT ISSUING FEE I certify that I have read this application and state that the TOTAL FEE 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 abov entioned property f r inspection purposes. SEE'REVERSE FOR EXPLA ATO GUAG/`9rVr . Si ature of Permittee Date COUNTY OF LOS ANGELES TEMPLE CITY # 0508 ELECTRICAL PERMIT DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS EL 0508 0312080010 BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 PHONE: (626) 285-0488 EXT: LEGA ID: FEES PAID BUILDING ADDRESS: TR: 6561 5939 GOLDEN WEST FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: LCNT CA ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET: LAS TUNAS 8587-025-903 Al PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: GRID: LOCALITY: TEMPLE CITY F1 120V, 15/20A BR CKTS 1.00 BR 17.25 TENANT: TOTAL FEES 45.00 ISSUED ON: PROCESSED BY: PLAN BY: EXPIRES ON: 12/11/03 JK 06/08/04 OWNER: TEL. NO: FINAL-j FINAL BY: CODE: TEMPLE CITY / DESCRIPTION OF WORK ELECTRICAL FOR NEW ADA COMPLIANT DOORS APPLICANT: TEL. NO: SHANNON G SULLIVAN (909) 599-2790- 146 E FIRST ST SPECIAL CONDITIONS: SAN DIMAS 91773 CONTRACTOR: TEL. NO: APPROVALS DATE INSPECTOR SIGNATURE SULLIVAN ELECTRIC (909) 599-2790- 146 E FIRST ST LIC. NO TEMPORARY POWER POLE SAN DIMAS, CA 91773 816933 C10 UNDERr,ROUND CONDUIT ARCHITECT OR ENGINEER: TEL. NO: UFER GROUND LIC. NO: ROUGH CONDUIT ROUGH WIRING MAIN 'WATER LINE PLASTIC Y/N METAL Y/N UTILITY COMPANY NOTIFIED REPORT ID: DPR265 ROUTE TO: BS0508