HomeMy Public PortalAbout9650 LA ROSA DR_Electrical__ yVORKERS'DGMPENSATIDN DECLARATION 96-863 ,D,S,
CE-806G APPLICATION FOR ELECTRICAL PERMIT
N hereby affirm 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.) 4 .r *moi '
Policy NnraJhd 9t�7 Compeny`-'� dapi FOR APPLICANT TO FILL IN JOB
Certified copy is hereby furnished. New Residential Bldgs.& Pools EACH NO. FEE ADDRESS `mNCI f�H
CerI fi d opy is filed with the county building inspection 1 & 2-Family,Sq.Ft. $ _ $ LOCALITY %C e
doe
m L Multi-family Sq.FL NEAREST
CROSS ST. ^
Dale _/ryL B/l✓
S .I Applicant Residential Swimming Pools OWNER OR
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS'• Outlets:Ree— Light _ Sw..— MAIL A
COMPENSATION INSURANCE - - ADDRESS eS� OSry "
(This section need not be ccmpleted if the work involved by the First 20
permit is for one hundred dollars($100) or less.). Total No. Additional CITY Tel.No.IZZ 011.30 1
I certify that in the performance of the work for which this permit PLAN CHECK
APPLICANT
is issued, I shall not employ anyperson in any manner so as to
become subject to.theWorkers'Compensation Laws. Lighting Fixtures First 20 ADDRESS
1. Total No. Additional CITY Tel.No.
Date Applicant Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption,you should become subject to the Workers'Compensation Range_ HeaterD.W. _ APPLICANT
provisions of the Labor Code, you must forthwith comply with such Oven _ Dryer _ W.M. _ ADDRESS 3
provisions or this permit shall be deemed revoked. Top _ FAU W.H.
CITYTel.No ./2�
LICENSED CONTRACTORS DECLARATION Hood _ Fan Other_ q
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. LICENSE OR r( class.
(commencing with Section 7000) of Division 3 of the Business and REG.NUMBER p
Professions Code,andmy license is in full force and effect. Power Apparatus 8 Large Appliances DISTRICT NO PROCES D By
��]]'/p( Size & Type HP,KW,KVA,or KVAR
�1�/� O
License Number;!NV` Le.Class Up to'1 Incl. FINAL V
Over 1 to 10 Ind. _ DATE VALIDATION O
C ntract r Over 10 to 50 Incl. FIN- 1
❑ I am exempt under Sec. Over 50 to 100 Inc. gy W
B.&P.C.for this reason Over 100 a-
Services,Swbd., MCC& Penelboards 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 - 1
I hereby affirm that I am exempt from the Contractor's License Law - -
Additional Sign Branch Circuits f'
for the following reason(Section 7031.5, Business and Professions •�
Code): 37 r
J_
El 1.
Conduits & Conductors I,as owner of the property,will do the work and the structure FOG
is not intended or offered for sale (Section 7044, Business Other (See Complete Fee Schedule) _
and Professions Cade). - ► T' Y I :32 9=0
CONSTRUCTION LENDING AGENCY 12a50
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) - alfa
Civ.CJ.
PLAN.CHECKING FEE _
Lender's Name y� [I r�1'�17 1/
PERMIT ISSUING FEE /v ,sCJ
Lender's Address Z� >`"~✓ + AN M61 certify that I have read this application and state that the above TOTAL FEE �.3
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
proper v for inspection pur ses.
/C .. SEE REVERSE FOR EXPLANATORY LANGUAGE
Si
gnatu of Permittee Date
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 ELECTRICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS EL 0508 0511090048
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0486 EXT:
LEGAL ID: FEES PAID BUILDING ADDRESS:
TR: 14467 LT: 76 9650 LA ROSA DR
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917B03860
ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET: TEMPLE CITY
8589-017-024 Al PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 597 GRID: A4 LOCALITY: TEMPLE CITY, C
G1 OUTLETS-LGT,SW,RECP 52.00 OUT 82.20
TENANT: G2 LIGHTING FIXTURES 24.00 LGT 44.40 ISSUED ON: PROCESSED BY: PLAN BY: EXPIRES ON:
HA PAU LESS 3HP 1.00 PAD 10.95 11/10/05 JK 05/09/06
H2 RES GREG DISP LT 3HP 1.00 DIS 10.95
OWNER: TEL. NO: H3 RES DISHWASHR LT 3HP 1.00 DIS 10.95 FINAL DATE FINAL BY: CODE:
HEASLIP SCOT W;OLACHEA-HEASLIP ROSE (626) 2B6-3922- H4 RES RANGE BOB LT 3HP 1.00 ROD 10.95
9650 LA ROSA DR JB AC UNITS ♦3-10HP 1.00 AC 19.65
TEMP 917803B60 LB 200 AMP PANELS, MCC 1.00 PAN 38.85 DESCRIPTION OF WORK
TOTAL FEES 256.65 ELECTRICAL FOR ADDITION, REMODEL AND UPGRADE SERVICE PANEL
200 AMP
APPLICANT: TEL. NO:
HEASLIP (626) 286-3922-
SPECIAL CONDITIONS:
CONTRACTOR: TEL. NO: APPROVALS DATE INSPECTOR SIGNATURE
TOM O'LEARY CONSTRUCTION (626) 287-0927-
5823 AGNES AVENUE LIC. NO TEMPORARY POWER POLE
TEMPLE CITY, CA 91780 489354 B-1
UNDERGROUND CONDUIT
ARCHITECT OR ENGINEER: TEL. NO: UFER GROUND
LIC. NO: ROUGH CONDUIT
ROUGH WIRING
MAIN WATER LINE
PLASTIC YIN METAL YIN
UTILITY COMPANY NOTIFIED
REPORT ID: DPR265 ROUTE TO: BS0508