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Home My Public Portal About4905 HALLOWELL AVE_Electrical__ o WORKER'S COMPENSATION DECLARATION 9 DPW 9/89 76A663 APPLICATION FOR ELECTRICAL PERMIT 76A66 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 thereof(Sec.3800 Lab.C.) Policy NO. Company FOR APPLICANT TO FILL IN JOB ADDRESS L19051 Certified copy is hereby furnished. New Residential Bldgs.&Pools EACH NO. FEE LOCALITY ❑ 1 &2-Family,Sq.Ft. $ $ Certified copy is filed with the county building inspection NEAREST department. Multi-family Sq.Ft. CROSS ST. Date Applicant Residential Swimming Pools ASSESSOR MAPBOOK PAGE PARCEL CERTIFICATE OF EXEMPTION FROM WORKERS' � Z OWNER OR / COMPENSATION INSURANCE Outlets:Rec. Light Sw. / FIRM NAME L, First 20 MAIL (This section need not be completed if the work involved by the Total No. Additional ADDRESS QS e(j(� permit is for one hundred dollars($100)or less.) I certify that in the performance of the work for which this permit CITY Tel.No. -167 is issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws. Lighting Fixture/ First 20 CHECK0 PLAN APPLICANT Total No. Additional ADDRESS Date Applicant 15 OR 20A,120V BRANCH CIRCUITS NOTICE TO APPLICANT: If, after making this Certificate of CITY Tel.No. Exemption,you should become subject to the Workers'Compensation 1 TO 10 INCLUSIVE EACH IT provisions of the Labor Code, you must forthwith comply with such 11 TO 40 INCLUSIVE EACH APPLICANT provisions or this permit shall be deemed revoked. 41 OR MORE BRANCH CIRCUITS EACH LICENSED CONTRACTORS DECLARATION ADDRESS a I hereby affirm that I am licensed under provisions of Chapter 9 15 OR 20A,208V TO 277V LIGHTING EACH O (commencing with Section 7000) of Division 3 of the Business and CITY Tel.No. Professions Code,and Amy license is in full force and effect. RESIDENTIAL APPLIANCES UP TO 3HP LICENSE OR LL Power Apparatus&Large Appliances REG.NUMBER Class. License Number Lic.Class Size&Type HP,KW,KVA,or KVAR DISTRICT NO. PROCESSED BY Up to 3 Incl. �G� � �_ W Over 3 to 10 Incl. FINAL t2 Contractor Date Over 10 to 50 Incl. DATE ,r� Z 2- z ElI am exempt under Sec. Over 50 to 100 Incl. �i FINAL VALIDATION B.&P.C.for this reason Over 100 BY / Services,Swbd.,MCC&Panelboards Date: 0-200 Amp.Under 600 V Signature 201 -1000 Amp.Under 600 V ❑ Over 1000 Amp.or Over 600 V Exemption for Reg.Maint.Elect. ,_. SINGLE FAMILY Temp. Power Pole&Appurtenances HOME OWNER-BUILDER DECLARATION r r a I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit 1$,•i z for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits s Code): _t 4k.i. ?_+ LpL I,as owner of the property,will do the work and the structure Misc.Conduits&Conductors - - is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) , and Professions Code). - i•H"' c CONSTRUCTION LENDING AGENCY _ 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 - •� 8',��-� Lender's Address / / I certify that I have read this application and state that the above TOTAL FEE information is correct. I agree to comply with all County ordinances and State laws regulating Electrical wiring, and hereby authorize representatives of this u to enter upon the above-mentioned prop rty for.ins ection rp se . SEE REVERSE FOR EXPLANATORY LANGUAGE SIG ATUR FA RAGE E A, .WORKERS'COMPENSATION DECLARATION 8 10/81 CE-80606G APPLICATION FOR ELECTRICAL PERMIT {� CE- LJ I he*by affirk,that I have a certificate of consent to self insure, or a certificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY copy thereof(Sec.3800,Lab. C.) Policy No. Company ' FOR APPLICANT TO FILL IN JOB �D� /� j ❑ Certified co is hereby furnished. EACH NO. FEE ADDRESS (i(,Q PY Y New Residential Bldgs.& Pools ❑ _ Certified copy is filed with the county building inspection 1 & 2-Family,Sq.Ft. $ $ LOCALITY NEAREST department. Multi-family Sq.Ft. CROSS ST. ( r J6 Date Applicant Residential Swimming Pools OWNER OR FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec Light Sw. MAIL COMPENSATION INSURANCE ADDRESS (This section need not be completed if the work involved by the First 20 CITY Tel.No. permit is for one hundred dollars ($100)or less.) Total No. Additional �o�/lo� I certifythat in the performance of the work for which this permit PLAN CHECK p P APPLICANT is issued, I shall not employ any person in any manner s as to become subject to the Workers'Compens tion.Laws. Lighting Fixtures First 20 ADDRESS Additional _ Total No. CITY Tel.No. Date Applicant Fixed Appliances Not Over 1 HIP NOTICE TO APPLICANT: If, after making this Certificate of PERMIT Exemption,you should become subject to the Workers'Compensation Range_ Heater_ D.W. _ APPLICANT provisions of the Labor Code, you must forthwith comply with such Oven _ Dryer _ W.M._ ADDRESS provisions or this permit shall be deemed revoked. Top — FAU _ W.H. — CITY —6r 4111 Tel.No. LICENSED CONTRACTORS DECLARATION Hood — Fan _ Other_ I hereby affirm that I am licensed under provisions of Chapter 9 LICENSE OR Disp. ROOM Air B Cond. REG.NUMBER Class. (commencing with Section 7000) of Division 3 of the Business and Professions Code,and my license is in full force and effect. Power Apparatus& Large Appliances DISTRICT NO. P CES D BY Size& Type HP, KW,KVA,or KVAR , 00 License Number Lic.Class Up to 1 Incl. FINAL / U Over 1 to 10 Incl. DATE VALIDATION ct Contractor DateOver 10 to 50 Incl. j ElFINAL I am exempt under Sec. Over 50 to 100 Inc. BY a Over 100 BAP.C. for this reason fA Services, Swbd.,MCC & Panelboards Z Date: 0- 200 Amp.Under 600 V Signature 201 - 1000 Amp.Under 600 V ❑ Over 1000 Amp.or Over 600 V Exemption for Reg.Maint.Elect. SINGLE FAMILY Temp.Power Pole& Appurtenances 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 Code): I,as owner of the property,will do the work and the structure Misc.Conduits & Conductors is not intended or offered for sale (Section 7044, Business Other (See Complete Fee Schedule) and Professions Code). CONSTRUCTION LENDING AGENCY i'7 3 2 4 A 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) # 0 0 0 0.0 2 Civ. C.). PLAN CHECKING FEE `i' o o2,550 Lender's Name o 0 0 25.5 0 63 PERMIT ISSUING FEE Lender's Address 0624-87 1 certify that I have read this application and state that the above TOTAL FEE 5� 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 propert for inspection pur s SEE REVERSE FOR EXPLANATORY LANGUAGE ' L-ZL/- S gnature of Permittee Date d COUNTY OF LOS ANGELES TEMPLE CITY # 0508 ELECTRICAL PERMIT DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS EL 0508 1109260021 BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 PHONE: (626) 285-0488 EXT: (LEGAL ID: I FEES PAID I BUILDING ADDRESS: I I ON FILE 1 I 4905 HALLOWELL AV I I IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT: ( TEMP CA 917803459 I 1ASSESSOR INFORMATION NUMBER: I I NEAREST CROSS STREET: LOWER AZUSA I 18585-016-007 1A1 PERMIT ISSUANCE FEE 27.80 I THOMAS PAGE: 597 GRID: C4 LOCALITY: TEMPLE CITY CAI I G1 OUTLETS-LGT,SW,RECP 5.00 OUT 9.70 1- 1 (TENANT: IG2 LIGHTING FIXTURES 1.00 LGT 1.90 (ISSUED ON: PROCESSED BY: PLAN BY: 1 TOTAL FEES 39.40 109/26/11 SR I I I I I (OWNER: TEL. NO: I (FINAL DATE FINAL BY: CODE: 1 1DAVIS MICHAEL D;SUZANNE M 14901 HALLOWELL AV 1 2�1( -1 1 ITEMP 917803459 I IDESCRIPTION OF4WORK I 1 1ELECTRICAL FOR NEW ADDITION 5 OUTLETS AND 1 LIGHT FIXTURE 1 I I I I (APPLICANT: TEL. NO: 1 1 IEDGLEY & SONS (626) 818-9385- 1 14847 KAUFFMAN AVE 1 1SPECIAL CONDITIONS: 1 ITEMPLE CITY CA 91780 I I I I I I I I I ICONTRACTOR: TEL. NO: I 1APPROVALS DATE INSPECTOR SIGNATURE I IEDGLEY AND SONS (626) 818-9385- 1 1 1 14847 KAUFFMAN AVENUE LIC. NO I (TEMPORARY POWER POLE I I 1 ITEMPLE CITY, CA 91780 528990 B I I I 1 I (UNDERGROUND CONDUIT I I I I I I I I (ARCHITECT OR ENGINEER: TEL. NO: IUFER GROUND I I I IINING LU CONSULTING STRUCTUAL (818) 795-1250- I 1 1 1 12500 E FOOTHILL BLVD SUITE 211 LIC. NO: I IROUGH CONDUIT I IPASADENA CA 91107 RPE 3042 I 1 I I IROUGH WIRING IMAIN WATER LINE 1 IPLASTIC Y/N METAL Y/N 1 I I I I I I I I . I - - (UTILITY COMPANY NOTIFIEDI I I I I I I I I I I I I I I I I I I I i I I I I I I I I I I I I I I I I I I I I I i I I I I I ! I I I I I I I I I I I I I I I I I I I I I I I I i I I I I I I I I I I I I I I I I I I I I I I I I I I I I (REPORT ID: DPR265 ROUTE TO: BS0508 I I I I I I