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Home My Public Portal About5009 KAUFFMAN AVE_Electrical__ WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12-91) APPn ICAT8®N FOR ELECTRICAL( PERMIT .776A663 � LL u� � udu 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. OF PUBLIC WORKS BUILDING AND SAFETY DIV. copy thereof(Sec. 3800 Lab. C.) Policy NO. 'Company FOR APPLICANT TO FILL IN JOB ADDRESS ❑ Certified copy is hereby furnished. New Residential Bldgs.&Pools. NO. EACH FEE IL Certified.co is filed with the count building inspection 1 &2-Family,Sq.Ft. — $ $ LOCALITY'7,C(`1 PLC py y g p - NEAREST !1 C• ' department. Multi-family Sq.Ft CROSS ST. �..4 Date Applicant Residential Swimming Pools ASSESSOR MAP BOOK PAGE PARCEL CERTIFICATE OF EXEMPTION FROM WORKERS' Cutlets:Rec. Light L Sw. ' OWNER OR COMPENSATION INSURANCE v FIRM NAME 11y/1E �•T First 20 (This section need not be completed it the work.involved MAIL involved by the p pC permit is for one hundred dollars(5100)or fess.) J Total No. 'Additional ADDRESS � ( /�. 1 certify that in the performance of thework for which this permit CITY Cr Tel.No. 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 ADDRESS Date Applicant RESIDENTIAL APPLIANCES NOT OVER 3 HP NOTICE TO APPLICANT:.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 - 'w , provisions or this permit shall be deemed revoked. Power Apparatus&Large Appliances APPLICANT ��/t/ LICENSED CONTRACTORS DECLARATION Size&Type HP,KW4K-VA,or KVAR ADDRESS I hereby affirm that I'am licensed under provisions of Chapter 9 a� (commencing with Section 7000) of Division 3 of the Business and Over to 10 Incl. CITY Tel.No. Professions Code,and my license is in full force and effect. Over 10 to 50 Incl. LICENSE OR Class. Over 50 to 100 Incl. REG.NUMBER �- Over 100 DISTRICT NO. SED BY P 0 License Number Lia Class n ,,,aaappp��---gggsss V .11Services,Swbd.,MCC&•Panelboards Contractor Date 0-399 Amp.Under 600 V DATE O EJ 400-1000 Amp, Under 600 V ,. V I am exempt under Sec. VALIDATION LU Over 1000 Amp.or Over 800 V FINAL 13 B.&P.C.for this reason BRANCH CIRCUIT FEES BY- W Date: 15A,or 20A,120V,Lighting or_Recept. 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 - t !ifeJL HOME OWNER-BUILDER DECLARATION. Sign with One Branch Circuit -��,- I hereby affirm'that I am exempt from the Contractor's License Law �� 7 for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits Code): 1ITEMS 1, as owner of the property, will do the work and the structure Misc.Conduits&Conductors ` �ijii ® ,l�k is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) AL r,L�y.�Yy and Professions Code). CHECK `.tnVLJ CONSTRUCTION LENDING AGENCYCHANGE .011 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) a� Civ.C.) PLAN CHECKING FEE xy 0000-001011 000-0010 iii A?kI1f 2/93 Lender's Name - ............-.._. . G'1'Y+J - 1 {'1!IliR=9 PERMIT ISSUING FEE Lender's Address / 0 I certify that I have read this application and under penalty of purjury state TOTAL FEE 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 toe ter upon the above-mentioned.property for ins ct' n purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE SIG TURE OF PE EE DATE COUNTY OF LOS ANGELES TEMPLE CITY # 0508 ,ELECTRICAL PERMIT DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS EL 0508 9905190006 BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 PHONE: (626) 285-0488 EXT: LEGAL ID: FEES PAID BUILDING ADDRESS: TR: 14832 LT: 7 5009 KAUFFMAN AV FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917803944 ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET: 8589-017-008 Al PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 597 GRID: A4 LOCALITY: TEMPLE CITY G1 OUTLETS-LGT,SW,RECP 15.00 OUT 29.25 TENANT: G2 LIGHTING FIXTURES 5.00 LGT 9.75 ISSUED ON: PROCESSED BY: PLAN BY: EXPIRES ON: LN OTHER PNL 0-399 AMPS 1.00 PAN 38.85 05/19/99 UT 11/15/99 TOTAL FEES 105.60 OWNER: TEL. NO: FINAL DATE FINAL BY: CODE: SWANTON JOHN W;SARA G TRS (626) 286-8519- ' 5009 KAUFFMAN AV o TEMP 917803944 DESCRIPTION OF WOR ELECTRICAL FOR WORK SHOP APPLICANT: TEL. NO: SAME AS OWNER - SPECIAL CONDITIONS: CONTRACTOR: TEL. N0: �� APPROVALS DATE INSPECTOR SI TURE SAME AS OWNER LIC. NO TEMPORARY POWER POLE UNDERGROUND CONDUIT ARCHITECT OR ENGINEER: TEL. NO:, UFER GROUND LIC. NO: 1111111 ROUGH CONDUIT ROUGH WIRING 6-z �U n OMC ORKS MAIN WATER LINE U PLASTIC Y/N METAL Y/N UTILITY COMPANY NOTIFIED n - ser " O 0. voce 1 REPORT ID: DPR265 ROUTE TO: BS0508 WORKERS'COMPENSATION tate.DFZ!ZLARA iN �Pp OCATOON FOR ELECT IC/A L PERM OT I ,hc;eby affirm that I have a certificate 'o` isen>, e,lf � - -.m ll� !fes I� Il`SIICN® to insure, or a certificate of Workers' Corn p'e nspi an�lnsu ,q e, COUNTY OF LOS ANGELES BUILDING AND SAFETY or a certified copy thereof (Sec. 3800, Lab. C. _ Policy No._ Company - ri FOR APPLICANT TO FILL:IN r_;' .JOB Certified copy is hereby furnished New Residential Bldgs. & Pools PAC %NO. _ FEE-. ADDRESS � O0— $ LOCALITY � ❑ Certified copy is filed with the county building mspec- T 8 2-4mily, Sq. Ft. t�dC T L tion department. Multrfamil S Ft. — NEAREST p ;Reside.ntial Swimming Pools OWNER OR Of� Date Applicant FIRM NAME L? JAI G(J /y CERTIFICATE OF EXEMPTION FROM WORKERS O MAIL J/ f )utlets: Rec r' Light Svv.�, r �(• COMPENSATION INSURANCE o ADDRESSFirst 20 �/J/�`e (This section need not be completed if the work involved by ' Total No. Additional e�+ CITY ��L(�1C� L�i f Tel. No. the permit is for one hundred dollars($100)or less.)' PLAN CHECK I certify that in the performance of the'work for which this;.; } APPLICANT C� permit is issued, I shall not employ any person in any manner, so as to become subject to the Workers'Com ensation Laws.; ighpting Fixtures First 20 ADDRESS Additional Total No. C CITY "- Tel. No. Date L�I.J! Applicant ` ,.Fixed:Appliances Not Over 1 HP PERMIT NOTICE TO APPLICANT: If, after mal'ng this Certificate of, APPLICANT - Exemption, you should become s ject to the Workers' +,• Ronge_ Heater_D.W. — Compensation provisions of the Labor Code, you must forth-_ Oven _ Dryer — W.M.— ADDRESS with comply with such provisions or this permit shall be (_Tdp FAU —W.H. — deemed revoked. Hood Fan Other_ CITY Tel. No. _ _ LICENSED CONTRACTORS DECLARATION LICENSE OR I hereby affirm that I am licensed under provisions of Chapter 9 Disp. _ Room Air Cond. REG. NUMBER �' Class. (commencing with Section 7000) of Division 3 of the Business DISTRICT NO. PROCESSE BY and Professions Code, and my license is in full force and effect. Power Apparatus& Large Appliances } Size &Type HP, KW, KVA, or KVAR' �� Q License Number_ Lic. Class Up to 1 Incl FINAL � V Over 1 to 10 Incl. DATE �" v' VALIDAT N '0 Contractor Date Over 10 to 50 Incl. FINAL Q ElI am exempt under Sec. Over 50 to 100 Inc. BY 9 ;' rilaCt 8.&P.C. for this reason Over 100 Services, Swbd., MCC & Panelboards `/l! Date: 0 -200 Amp. Under 600 V g` Signature 201 - 1000 Amp. Under 600 V 1 5 1.9 A Over 1000 Amp. or Over 600 V # o o o 0 o 2 ❑ Exemption for Reg. Maint. Elect. ( o - 61.75 SINGLE FAMILY Temp. Power Pole & Appurtenances o 0 0 6 1,7 5 HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit I hereby affirm that I am exempt from the Contractor's Licenseadditional Sign Branch Circuits Q 1. 09-85 Law for the following reason (Section 7031.5, Business and Professions Code): ❑ I, as owner of the property, will do the work and the Misc. Conduits &Conductors structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ 7044, Business and Professions Code). 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) (Sec. 3097, Civ. C.). PLAN CHECKING FEE Lender's Name PERMIT ISSUING FEE Lender's Address 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 lows regulating Electrical wiring,.and hereby authorize representatives of this County to enter upon thea e-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE sigttLfre of Perm' tee Date