HomeMy Public PortalAbout5807 KAUFFMAN AVE_Electrical__ WORKERS' COMPENSATION DECLARATION 76A663 10/81
_liereb> affirm that I have a certificate of consent to self insure, CE-8066 APPLICATION FOR ELEC/TRIPAL PERMIT
or a certificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES f -6'/O��/ ILDING AND SAFETY
co/p�y the of(Sec.3800,Lab. C.)
Pofic��� Company`- 7' (tJ /Vg�J`� FOR APPLICANT TO FILL IN JOB
❑ Certified copy is hereby furnished. EACH NO. FEE ADDRESS / m f N
New Residential Bldgs.& Pools l
Certified copy is filed with the county building inspection
1 & 2-Family,Sq.Ft. $ — $ LOCALITY G
department. Multi-family Sq.Ft. NEAREST
d Residential Swimming Pools CROSS ST.
late — / Applicant 1y- �Q���L OWNER OR
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec I Light .I Sw. MAIL
COMPENSATION INSURANCE n 5 3 ADDRESS t( /terry N
(This section need not be completed if the work involved by the ? First 20
permit is for one hundred dollars($100)or less.) Total No. Additional CITY 7—G' Tel.No. _YGV7
I certify that in the performance of the work for which this permit PLAN CHECK
APPLICANT
is issued, I shall not employ any person in any manner s0 as to
become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS
Total No. Additional CITY Tel.No.
Date Applicant Fixed Appliances Not Over 1 HP PERMIT /) //77 �,(
NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT U/U/�Or2 /t(�L (_dNo-( LjVc--
Exemption,you should become subject to the Workers'Compensation Range_ Heater_ D.W.
provisions of the Labor Code, you must forthwith comply with such Oven _ Dryer _ W.M. _ ADDRESS N
provisions or this permit shall be deemed revoked. Top _ FAU _ W.H. CITY E,�y (P `� Tel.No. –3/�7
LICENSED CONTRACTORS DECLARATION Hood — Fan _ Other_
II I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. _ LICENSE OR Class.
5G J
(commencing with Section 7000) of Division 3 of the Business and REG.NUMBER
Professions Code,and my license is in full force and effect. DISTRICT NO. PROCE BY
License Number OJ /'7 Lic.CI
2 S Power Apparatus& Large Appliances iL
3 5
e�J Size & Type HP, KW,KVA, or KVAR + �✓ Q
Class .39 Up to 1 Incl. FINAL '
s
�dNN02 ,Q �x� /J 3J._ Over 1 to 10 Incl. DATE – �� VALIDATION 0
Contractor. /1 i2 Date 7� Over 10 to 50 Incl. FINA V
❑ I am exempt under Sec. �Z Over 50 to 100 Inc. gY W
Ll'
B.&P.C.for this reason Over 100 Cl)
Date:
Services,Swbd.,MCC& Panelboards ► Z
0 - 200 Amp.Under 600 V
Signature 201 - 1000 Amp.Under 600 V
❑ Exemption for Reg.Maint.Elect. Over 1000 Amp. or Over 600 V
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 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 16
Lender's Address
1 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 County to enter upon the above-mentioned
pro for inspection purpose .
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee 3—
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 ELECTRICAL PERMIT
DEPARTMENT OF PUBLIC WORKS :•s ';i i'` 9701 LAS TUNAS EL 0508 0110220016
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
LEGAL D: FEES PAID B ILDING DDRESS:
TR: 6561 LT: 513 5807 KAUFFMAN AV
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917802206
ASSESSOR INFORMATION NUMBER: — NEAREST CROSS STREET: LAS TUNAS
8587-021-003 Al PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 597 GRID: A3 LOCALITY: TEMPLE CITY
F1 120V, 15/20A BR CKTS 1.00 BR 17.25
TENANT: H2 RES GRBG DISP LT 3HP 1.00 DIS 10.95 SSUED ON- PROCESSED BY: PLA BY: EXPIRES ON:
LB 200 AMP PANELS, MCC 1.00 PAN 38.85 10/22/01 JK 04/20/02
TOTAL FEES 94.80
OWNER: TEL. NO: FINAL DATE BY: CODE:
WERNER; HELEN F. (626) 447-4967- EXPIN
348 W. CAMINO REAL
ARCADIA 91007 DESCRIPTION R
UPGRADE SERVICE PANEL, REPLACE GARBAGE DISPOSAL
APPLICANT: TEL. NO:
SAME AS OWNER
SPECIAL CONDITIONS:
CONTRACTOR: TEL. N0: � � / e:�G,���V APPROVALS DATE INSPECTOR SIGNATURE
SAME AS OWNER
LIC. NO �i� p�� TEMPORARY POWER POLE
UNDERGROUND CONDUIT
ARCHITECT OR ENGINEER: TEL. N0: i/ L — \ LIFER GROUND
LIC. N0:" ROUGH CONDUIT y
ROUGH WIRING
MAIN WATER LINE
PLASTIC Y/N METAL Y/N
-- -- - - --- — — — - -- % UTILITY COMPANY NOTIFIED
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REPORT ID: DPR265 ROUTE TO: SS0508
COUNTY OF LOS .ANGELES TEMPLE CITY # 0508 ELECTRICAL PERMIT
DEPARTMENT PF PUBLIC WORKS 9701 LAS TUNAS EL 0508 0804150024
BUILDING FIND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
LEGAL ID: FEES PAID BUILDING ADDRESS:
ITR: 6561 LT: 513 5807 KAUFFMAN AV
I 1FEE DESCRIPTION: QUANTITY: UOM: AMOUNT-.1 TEMP CA 917802206
ASSESSOR INFORMATION NUMBER: I I NEAREST CROSS STREET:
18587-021-003 1A1 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 597 GRID: A3 LOCALITY: TEMPLE CITY, Cl
1 1LB 200 AMP PANELS, MCC 1.00 PAN 38.85 1
TENANT: I TOTAL FEES 66.60 JISSUED ON: PROCESSED BY: PLAN BY: EXPIRES ON: 1
1 104/15/08 SR 10/12/08 1
1OWNER: TEL. NO: 1 1FL DATE FINAL BY: CODE: 1
1LAM, QUANG (626) 215-7412- 1 1 15807 KAUFFMAN AVENUE I2Q`
1TEMPLE CITY CA 91780 1 I ,IPTION OF WORK 1
1 1RELOCATE AND UPGRADE SERVICE PANEL TO 200 AMP 1
1APPLICANT: TEL. NO: I I I
1LAI (626) 288-2651- 1
18748 VALLEY BLVD. #K 1 1SPECIAL CONDITIONS: 1
1ROSEMEAD, CA 91770 1 1
I I I I
1CONTRACTOR: TEL. NO: 1 (APPROVALS DATE INSPECTOR SIGNATURE 1
IQUANG T LAM (626) 215-7412- 1 1I
1XIA0 YING MAI LIC. NO 1 1TEMPORARY POWER POLE 1 I
19303 RALPH STREET NONE I I I I
1ROSEMEAD, CA 91770 1 (UNDERGROUND CONDUIT I I I
I I I I I I
1ARCHITECT OR ENGINEER: TEL. NO: 1UFER GROUND I I
1LEE, PETER (626) 280-9000- 1 I I
18748 VALLEY BLVD. #L LIC. NO: 1 1ROUGH CONDUIT I I I
IROSEMEAD CA 91770 NONE * 1 I I I I
I ( 1ROUGH WIRING
I I I
1 I IMAIN WATER LINE 1 1
I IPLASTIC YIN METAL YIN I I
I I I I I I
I 1 1UTILITY COMPANY NOTIFIEDI I I
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I* ADDITIONAL DATA ON FILE I I
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I IREPORT ID: DPR265 ROUTE TO: SS0508 1 I I I
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COUNTY OF LOS ANGELES TEMPLE CITY # 0508 ELECTRICAL PERMIT
DSPARTMENP OF PUBLIC WORKS 9701 LAS TUNAS EL 0508 0803120009
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
LEGAL ID: FEES PAID BUILDING ADDRESS:
JTR: 6561 LT: 513 5807 KAUFFMAN AV
IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT: ( TEMP CA 917802206
(ASSESSOR INFORMATION NUMBER: I I NEAREST CROSS STREET:
18587-021-003 IA1 PERMIT ISSUANCE FEE 27.75 I THOMAS PAGE: 597 GRID: A3 LOCALITY: TEMPLE CITY, Cl
I JB2 1 OR 2 FAMILY DWELL 640.00 SQ 67.20 D I
(TENANT: I TOTAL FEES 94.95 JISSUED ON: PROCESSED BY: PLAN BY: EXPIRES ON:
1 103/12/08 SR 09/08/08 I
DOWNER: TEL. NO: I IFINAL DATE FINAL BY: CODE: I
ILAM, QUANG (626) 215-7412- 1 1'6
15807 KAUFFMAN AVENUE 1 I
ITEMPLE CITY CA 91780 I JD SC IPTION OF WORK I
J I JELECTRICAL FOR 2ND: UNIT I
(APPLICANT: TEL. NO: I I I
ILAI (626) 288-2651- 1
18748 VALLEY BLVD. #K I ISPECIAL CONDITIONS: I
IROSEMEAD, CA 91770 I I 1
(CONTRACTOR: TEL. NO: JAPPROVALS DATE INSPECTOR SIGNATURE I
IQUANG T LAM (626) 215-7412- 1 1 1
IXIAO YING MAI LIC. NO 1 ITEMPORARY POWER POLE I I I
19303 RALPH STREET NONE I I- 1 1 1
IROSEMEAD, CA 91770 I JUNDERGROUND CONDUIT I I 1
I I I I I I
JARCHITECT OR ENGINEER: TEL. NO: I JUFER GROUND I I I
ILEE, PETER (626) 280-9000- 1 1 1 1 1
18748 VALLEY BLVD. #L LIC. NO: I IROUGH CONDUIT I 1
IROSEMEAD CA 91770 NONE I I 1
1 1 IROUGH WIRING 1 I1
I I I I I
1 1 IMAIN WATER LINE I 1
1 IPLASTIC YIN METAL YIN I 1
1 1 JUTILITY COMPANY NOTIFIED( 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
1* ADDITIONAL DATA ON FILE I I I 1
IREPORT ID: DPR265 ROUTE TO: BS0508 1 I 1 1
I I I I I I
• COUNTY OF LOS ANGELES TEMPLE CITY # 0508 ELECTRICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS EL 0508 0811030009
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT: '
ILEGAL ID: FEES PAID BUILDING ADDRESS:
ITR: 6561 LT: 513 I I 5807 KAUFFMAN AV I
I IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT: ( TEMP CA 917802206 1
(ASSESSOR INFORMATION NUMBER: I I NEAREST CROSS STREET:
18587-021-003 IA1 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 597 GRID: A3 LOCALITY: TEMPLE CITY, Cl
G1 OUTLETS-LGT,SW,RECP 14.00 OUT 27.30 I I
(TENANT: 1G2 LIGHTING FIXTURES 12.00 LGT 23.40 (ISSUED ON: PROCESSED BY: PLAN BY: EXPIRES ON: I
I I TOTAL FEES 78.45 111/03/08 SR 05/02/09 I
1OWNER: TEL. N0: I (FINAL DATE FINAL BY: CODE:
1
1LAM, TU QUANG (626) 215-7412-
15807 KAUFFMAN AVE. Iy �'� ►��
ITEMPLE CITY CA 91780 I ID SCRIPTION dF WORK 1
I 1ELECTRICAL FOR NEW ADDITION
I 1 I I
(APPLICANT: TEL. NO: I I
ILAI (626) 288-2651- I
18748 VALLEY BLVD. #K ISPECIAL CONDITIONS: 1
IROSEMEAD, CA 91770 I
ICONTRACTOR: TEL. NO: (APPROVALS DATE INSPECTOR SIGNATURE
IQUANG T LAM (626) 215-7412- 1 1 I
IXIAO YING MAI LIC. NO I ITEMPORARY POWER POLE I I I
19303 RALPH STREET NONE 1 I I I I
IROSEMEAD, CA 91770 1 1UNDERGROUND CONDUIT
I I I
(ARCHITECT OR ENGINEER: TEL. NO: I IUFER GROUND I I
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LIC. NO: I 1ROUGH CONDUIT 1 I
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I IROUGH WIRING I
I in,-0—A -7
1 I IMAIN WATER LINE I
I 1 IPLASTIC YIN METAL YIN
I I I
1UTILITY COMPANY NOTIFIEDI I I
1 I I I I I
I I I I I I
I I I I I I
I I I I I I
I 1 I I I I
I I I I I I
I i I I I I
I 1 I I I I
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I IREPORT ID: DPR265 ROUTE TO: BS0508
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