HomeMy Public PortalAbout8803 HERMOSA DR_Electrical__ � WORKERS' COMPENSATION DECLARATION .zaooro ovw 3ie7 APPLICATION FOR ELECTRICAL PERMIT O
1 hereb'affirm that Lhave a certificate of consent to self CE amG
5 sure, a, a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
or a certified copy thereof (Sec. 3800, Lab. C.) t
Policy No. Company FOR APPLICANT TO FILL IN JOB .,y J(
Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO, FEE ADDRESS .�/L� VJ/T
Certified copy is filed with the county building inspec- 1 & 2-Family, Sq. Ft. $ — $ LOCALITY
hon department. Multi-family Sq. Ft. — NEAREST
Residential Swimming Pools CROSS ST.
Dote q licant OWNER OR
pp FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec_Light_Sw._ MALL o
COMPENSATION INSURANCE ADDRESS V2w u/A-. #,�,y-s
(This section need not be completed if the work involved by First 20 CITY Tel, No. ) s,s��
the permit is for one hundred dollars ($100) or less.) Total No. Additional 3 ✓-�73
PAN CHECK
14
I certify that in .he performance of the work for which this APPLICANT
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Lows. Lighting Fixtures First 20 ADDRESS
Additional
Total No. CITY Tel. No.
Date Applicant !
NOTICE TO APPLICANT: If, after making this Certificate of Fixed Appliances Not Over 1 HP PERMIT
Exemption, you should become subject to the Workers' Range— Heater—D.W. — APPLICATION
Compensation provisions of the Labor Code, you must forth- Oven _ Dryer —W.M.— .ADDRESS
with comply with such provisions or this permit shall be Top — FAU —W.H. —
deemed revoked. Hood — Fan —Other_ CITY Tel. No.
LICENSED CONTRACTORS DECLARATION Disp. _ Room Air Cond. — LICENSE OR Class.
I hereby affirm that I am licensed under provisions of Chapter 9 REG. NUMBER
(commencing with Section 7000)of Division 3 of the Business Power Apparatus 8 Large Appliances DISTRICT NO. P C SSED Y >_
and Professions Code,and my license is in full force and effect. d
Size 8 Type HP, KW, KVA, or KVAR Q
License Number Lic. Class Q
Up to 1 Incl. FINAL
Over 1 to 10 Incl. DATE VALIDATION
Contractor Date Q
❑ Over TO to 50 Incl.
am exempt under Sec. Over 50 to 100 Inc. BY Al / / /�/ w
B.BP.C. for this reason Over 100 .✓ d
Date: Services, Swbd., MCC& Ponelboards / Z
0- 200 Amp. Under 60C
Signature 201 - 1000 Amp. Under 600 V
❑ Exemption for Reg. Mainz. Elect. Over 1000 Amp, or Over 600 V
SINGLE FAMILY Tem Power Pole 8 Appurtenances HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
.,3117 2c".50
1 hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits 1 TENS
P` rof7sions Code): TOTAL 25- 50
'R
Misc. Conduits 8 Conductors
I, as owner of the property, will f o the work and the 25 cif
structure is not intended or offered for sole(Section 7044, Other (See Complete Fee Schedule)_ �•HECf. ,.
Business and Professions Code). ' - - CHANGE - ,UO
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 PERMIT FEE (Sub-Total) 0000-0091 12/ 7185
(Sec. 3097, Civ. G).
PLAN CHECKING FEE 7346 1 iiI'ISI:1 +
Lender's Name
PERMIT ISSUING FEE
Lender's Address
I certify that I have read ap lication and state that the TOTAL FEE 5�
above inform is car . I gr 0 comply with all County
ordinances nd a s r g ting Electrical wiring, and
�e VI or ep s M .ry of this County to enter upon
th 0 v -m 'one pr r f r inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
ignature of Permute �f Date ®'
r
COUNTY OF LOS ANGELES TEMPLE CITY N 0508 ELECTRICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS EL 0508 1001250021
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91980
PHONE: (626) 285-0486 EXT:
ILEGAL ID: FEES PAID BUILDING ADDRESS: 1
'IR: 5904 IT 111 8803 HERMOSA DR
IFEE DESCRIPTION: QUANTITY- DOE: AMOUNT: ( TEMP CA 917801816
(ASSESSOR INFORMATION NUMBER: I I NEAREST CROSS STREET:
15366-011-050 1A1 PERMIT ISSUANCE FEE 29.75 1 THOMAS PAGE: 596 GRID: H3 LOCALITY: TEMPLE CITY, C1
I 1L8 200 AMP PANELS, MCC 1.00 PAN 38.85 I I
(TENANT: I TOTAL FEES 66.60 11SSDED ON: PROCESSED BY: PLAN BY: EXPIRES ON: 1
101/25/10 SR 01/25/11
OWNER: TEL. NO: FINAL DATE FINA B CODE:
YANAGIHARA, SHINICHI (626) 614-9424-
18803 HERMOSA DR I
ITEMP 917801816 DESCRIPTION OF WORK
1200 AMP SERVICE UPGRADE
(APPLICANT: TEL. NO: 1 II I
G S S ELECTRIC (323) 283-6317- I
1531 S. ATLANTIC BLVD (SPECIAL CONDITIONS: 1
MONTEREY PARK 91954
I
1CONTRACTOR: TEL. N0: I 1APPROVALS DATE INSPECTOR SIGNATURE 1
IG 6 S ELECTRIC (323) 283-6317- 1 1
1531 S ATLANTIC BLVD LIC. NO ITEMPORARY POWER POLE I I I
IMONTEREY PARK CA 91754 248057 C10
I 1UNDERGROUND CONDUIT I
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(ARCHITECT OR ENGINEER: TEL. N0: I JUFER GROUND o Il
LIC. NO: IROUGH CONDUIT
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TROUGH WIRING
(MAIN WATER LINE
(PLASTIC YIN METAL YIN
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(UTILITY COMPANY NOTIFIED
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I 1REPORT ID: DPR265 ROUTE T0: eS0508 I 1 1
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