HomeMy Public PortalAbout9207 LEMON AVE_Electrical__ tl WORKER'S COMPENSATION DECLARATION 2D-0019 DPW 9189
76A663 IVFO ATI APPLIC O ELECTRICAL R PERIUIIT
I harehy 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 PLUBLIC WORKS BUILDING AND SAFETY DIV.
copy thErpof(Sec.3800 Lab C.) , _ -
Policy No. Company r FOR APPLICANT TO FILL IN JOB' /Yr v
ADDRESS Cl
Certified
copy is hereby furnished. New Residential Bldgs.&Pools 'EACH NO. FEE LOCALITY
$
Certified copy is filed with the county building inspection' 1 &2.-Family,Sq.Ft. $ _ NEAREST
department. _ Multi-family Sq Ft. CROSS ST.
Date Applicant Residential Swimming Pools ASSESSOR
MAP BOOK PAGE PARCEL
V7-CERTIFICATE OF.EXEMPTION FROM WORKERS' ALF- 9 OWNER OR
COMPENSATION INSURANCE Outlets Rec Light Sw_= O� :FIRM NAMEZ3 A2 WAZ
First �r MAIL
permit,is for need not be comps($11 0 the work involved by the Total No � ' Additional ADDRESS G �
permit,is for one hundred dollars(5100)or,less.) '
I certify'that in the performance of the work for which this permit CITY 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
I 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
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 d
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 Tei No U
Professions Code, and my license is in full force and effect RESIDENTIAL APPLIANCES UP TO 3HP LICENSE OR Q
Power Apparatus&Large Appliances REG NUMBER Class O
? Size&Type HP,KW,KVA,or KVAR DISTRICT NO PR SED BY U
License Number Lic.Class p
Up to 3 Incl. .�� t a
Contractor Date Over 3 to 10 Incl DATE
Over 10 to 50 Incl. Z
F-1
I am exempt under Sec Over 50 to 100 Incl.- —� 7/ VALIDATION
Over 100 FINAL,
B,&P.C.for this reason BY
Services,Swbd.,MCC&Panelboards•. _
Date: 0 200 mp.Under 600 V
Signature -201--1000 Amp:Under 600 V
Over 1000 Amp.or Over 600 V
ET Exemption for Reg Maint.Elect
AL
SINGLE FAMILY Temp.Power Pole&Appurtenances I
HOME OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from'the Contractor's License Law Sign with One Branch Circuit
for the following reason (Section 7031.5, Business s and Professions Additional Sign Branch Circuits
Code): yy
I,as owner of the property,will do the work and the structure Misc Conduits&Conductors •r,OTA 'kk
is not Intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) O( 124 ® 0 6
and Professions Code). - - -a: i' 06
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) ;
rPLAN CHECKING FEE _ r' `«',.._ ., ( I IiI -110113 1 Q 125/I2
Lender's Namey �
PERMIT ISSUING FEE 5 �z { i° i
Lender's Address
TOTAL FEE
1 certify that I have read this application and'state 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 to enter upon the above-mentioned
property fo nsp ction purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE-
�C�TUJ OF&WLICANT-OR AGENT DATE _
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 ELECTRICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS EL 0508 0906150029
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
ILEGAL ID: I FEES PAID I BUILDING ADDRESS: 1
I ON FILE I 9207 LEMON AV I
IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT: ( TEMP CA 917801327 I
ASSESSOR INFORMATION NUMBER: I _ I NEAREST CROSS STREET:
15382-015-028 IA1 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 596 GRID: J1 LOCALITY: TEMPLE CITY, Cl
IJX MOTORS, LT 3 HP 1.00 MOT 15 30 I
(TENANT: I TOTAL FEES 43.05 (ISSUED ON: PROCESSED BY: PLAN BY: EXPIRES ON:
1 I 106/15/09 SR 12/12/09
(OWNER: TEL. NO: 1 IFINAL DATE, FINAI, BY CODE:
IBROWN DALE - I I
19207 LEMON AV I _1�
ITEMP 917801327 1 - IDtSCRIPTIOh OF WORK I
I I (ELECTRICAL FOR SOLAR PANEL I
(APPLICANT: TEL. NO:
ICHAVEZ (626) 622-0511- I I I
117011 GREEN DR. - I ISPECIAL CONDITIONS: I
ICITY OF INDUSTRY
I I I • I
(CONTRACTOR: TEL. NO: 1 (APPROVALS DATE INSPECTOR SIGNATURE I
(ELITE ELECTRIC (951) 681-5811- 1 1 I
19415 BELLEGRAVE LIC. NO 1 ITEMPORARY POWER POLE I I I
IRIVERSIDE CA 92509 418242 C10 I I I I 1
' (UNDERGROUND CONDUIT I I
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(ARCHITECT OR ENGINEER: TEL. NO: IUFER GROUND 1 I I
LIC. NO: IROUGH CONDUIT I I I
IROUGH WIRING I I
I IMAIN WATER LINE I I
IPLASTIC YIN METAL YIN I I I
I (UTILITY COMPANY NOTIFIED( I I
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I I I I I I
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I IREPORT ID: DPR265 ROUTE TO: BS0508 I I I I
I I I I I I
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 ELECTRICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS EL 0508 0111050011
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
LEGAL ID: FEES PAID BUILDING ADDRESS:
ON FILE 9207 LEMON AV
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917801327
ASSESSOR NFORMATION NUMBER: NEAREST CROSS STREET: OAK
5382-015-028 Al PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 596 GRID: J1 LOCALITY: TEMPLE CITY
G1 OUTLETS-LGT,SW,RECP 4.00 OUT 7.80
TENANT: G2 LIGHTING FIXTURES 2.00 LGT 3.90 ISSUED ON: PROCESSED BY: PLAN BY: EXPIRES ON:
TOTAL FEES 39.45 11/05/01 JK 05/04/02
OWNER: TEL. NO: FINAL DATE FINAL BY: CODE:
BROWN DALE E;VICTORIA A (626) 447-0062-
9207 LEMON AV
TEMP 917801327 DESCRIPTION OF WORK
ADD WORKSHOP TO EXISTING GARAGE
APPLICANT: TEL. NO:
SAME AS OWNER -
SPECIAL CONDITIONS:
CONTRACTOR: TEL. NO: APPROVALS DATE INSPECTOR SIGNATURE
SAME AS OWNER -
LIC. NO TEMPORARY POWER POLE
UNDERGROUND CONDUIT
ARCHITECT OR ENGINEER: TEL. NO: UFER GROUND
LIC. NO: ROUGH CONDUIT
f
ROUGH WIRING
MAIN WATER LINE
PLASTIC Y/N METAL Y/N
UTILITY COMPANY NOTIFIED
REPORT ID: DPR265 ROUTE TO: SS0508