Loading...
HomeMy Public PortalAbout5936 LOMA AVE_Electrical__ WORKERS'COMPENSATION DECLARATION 76-663 to/St APPLICATION ��gL��/�A�I®tlV ®� �����R®''�li� ���Mp,�y - I he�; c by affirm that I have a, ertificate,,of consent to-self insure,.. CE-806G IT ora certificz2e of WoN-,ers' Compensation An Insurance, or„a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY copy-,thereof(Sec.3800,Lab.C.) �/�Jy�' / Q Policy W'.- 9�b�Company 6 4 MO/UT V FOR APPLICANT TO FILL,IN JOB r/3� { ` '.A ❑ Certified copy'is hereby furnished. EACH NO. FEE ADDRESS�J lr�M Y New Residential Bldgs & Pools ❑ Q.,. Certified copy is filed with the county building inspection 1 & 2-Family, Sq.Ft_ -3;3 3�”I $ — $ Lie LOCALITYI. IqL c CITY department. Multi-family Sq.Ft. — NEAREST p / G} _ CROSS ST. Date eS d Applicant) �'"1W/q LZ� Residential Swimming Pools OWNER OR p �J . R.�FIRM NAME YT,C.JO J®N .• . CERTIFICATE.OF EXEMPTION FROM WORKERS' Outlets:Rec Light Sw. MAIL' eJ' COMPENSATION INSURANCE ADDRESS-735 wr—"EI�S,61V err L', First 20 a o .(This.section need not be completed if the work,involved by the. y pQQ Tel.NOR/ permit is for one hundred dollars,($100)-or less.) Total No. Additional CITY UQNTeR,5T rT� $'�'_* I certify that in the performance of the work for which this permit PLAN CHECK t Y P is issued, I shall not employ any person in any.:manner so as to APPLICANT become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS Additional Total No. CITY" Tel.No. Date Applicant Fixed Appliances Not Over,1 HP PERMIT NOTICE TO APPLICANT: If, after making this Certificate of PERMIT T LpN`i SI/lf 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 7 H`V^b't�`I R V E—Y -el-07 provisions or this permit shall be deemed revoked. Top — FAU .— W.H. LICENSED CONTRACTORS DECLARATION. Hood — Fan Other_ CITY/CnQS&/N/ b Tel.No 0.3 o -1�11 I hereby affirm that I am licensed under provisions of Chapter 9. Disp. — Room Air Cond. LICENSE OR (commencing with Section 7000) of Division 3 of the Business and - - REG.NUMBER Class. Professions Code,and my license is in full force and effect. DISTRICT NO. PROCESS Y Power Apparatus& Large Appliances r Size.& Type HP,KW,KVA,or KVARe D� License Number ) 2�- Lic.Class C—/0 Up to 1 Incl FINAL • V T o f R 0 Over 1 to 10 Inc[. DATE ��/L VALIDATION 0 Contractor LON PwA LEL Date A Over 10 to 50 Incl. U E] I am exempt under Sec. Over 50 to 100 Inc., FINAL BY BAP.C.for this reason Over 100 (n Services,Swbd.,MCC& Panelboards Z Date: 2 Amp.Under 600 V Signature �//�� �6AA Aey_ 201 - 1000 Amp.Under 600 V ` ❑ Over 1000 Amp.or Over 600 V Exemption for Reg.Maint.Elect. SINGLE:FAMILY Temp.Power Pole& Appurtenances 4 HOME OWNER-BUILDER DECLARATION Sign with One Branch'Circuit I hereby affirm that I am exempt from the Contractor's License Law C•'•_ „g, Branch Circuits. Sign n for the following reason(Section 7031.5,Business and Professions Additionalg _, -7 , Code) 3.0 r f_, .•. ❑ Misc.Conduits& Conductors 1 ITENI'L I,as owner of the property,will do the work and the structure is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) t and Professions Code). ® I ( i_ 17 , CONSTRUCTION LENDING AGENCY f_HECK '!�'95 I hereby affirm that there is a'construction'lending agency for theit;(-ANG athl performance of the work for which this permit is issued.(Sec.3097, PERMIT FEE (Sub-Total) Civ.C.). PLAN CHECKING FEE IIr —I�IlI - r z Lender's Name PERMIT ISSUING,FEE 06 r 172 _ f' A� •4ra a� Lender's-Address I certify that I have read this application and state that the above TOTAL FEE j 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 for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE, mc& al, f 0 . Signature of Permittee Date WORKERS'COMPENSATION DECLARATION. I CE-806G 10/81 APPLICATION FOR ELECTRICAL PERMIT I hereby affirm that I have a certificate.of consent to self insure, CE-8o6G /� \.r /1 fltVN or a.certficate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY -'copy thereof (Sec.3800,Lab.'C.) Policy No. - Company FOR APPLICANT TO FILL,IN JOB 3 " ❑ Certified copy is hereby furnished. New Residential Bldgs.& Pools EACH NO. FEE ADDRESS ❑ 1 & 2-Family,Sq.Ft. $ — $.p LOCALITY Certified copy is filed.with the .county building inspection NEAREST" , department. Multi-family Sq.Ft. CROSS ST: 0'I Residential Swimming Pools Date Applicant . OWNER OR. - _ FIRM NAME JA IAI .'- . CERTIFICATE OF EXEMPTION FROM WORKERS'. MAIL COMPENSATION IN Outlets:Rec Light Sw. -ADDRESS Q©Z LIN1�/4 WN (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 G Tel. N 'PLAN CHECK I certify that in the performance of the work for which this permit APPLICANT is issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 "ADDRESS Additional Total No. CITY Tel.No. Date Applicant Fixed Appliances Not Over 1 HIPPERMIT NOTICE TO`APPLICANT: If, after making this Certificate of Exemption,you should become subject to the.-Workers'Compensation Range_.Heat D.W, APPLICANT provisions.of the Labor Code, you must forthwith comply with such Oven Dryer W.M.,._ ADDRESS 3OZ L/AID4 �✓/ � provisions or this permit shall be deemed revoked Top FAU W.H. / LICENSED CONTRACTORS DECLARATION Hood - Fan Other_ CITY Tel.N J31` �7 I hereby affirm that I am licensed under provisions of 6.1 apter 9 Disp. — Room Air Cond. I LICENSE OR Class. (commencing with.Section 7000) of Division 3 of the'Business and REG:NUMBER Professions Code,and'my license is in full force and.effect. Power Apparatus& Large Appliances DISTRICT NO. .- PROCE D BY Size & Type HP,KW,KYA,or KVAR License Number Lic.Class i Up'to 1 Incl,: FINAL Over 1 to 10 Incl. DATE VALIDATION 0 Contractor Date Over 10 to 50 Incl. FINAL ❑ I am exempt under Sec. Over 50 to 100 Inc. BY V B.&P.C.for this reason Over 100 d Services,Swbd.,MCC& Panelboards Cl) Date: 0- 200 Amp.Under 600 V Z 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 y 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 IITEM��-+ ° is not intended or offered for sale (Section 7044, Business Other(See Complete.Fee Schedule) ® TOTAL 33 -00 and Professions Code). CONSTRUCTION LENDING AGENCY CHECK i!3.0 C i 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), -CHANGE I Civ. C.). PLAN CHECKING FEE . fill lii--`1 SSI1 5f ���r? Lender's Name AN 1 o ti J " PERMIT ISSUING.FEE ;� •, z r c Lender's Address /� I certify that I have read this application and state that the above TOTAL FEE ll v 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 for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE_ Q Signa of P-ermitte6 V Q Dae COUNTYOFLOS ANGELES TEMPLE CITY 4`0508 ELECTR-ICAL PERMIT- � - DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS EL 0508 0505200002 BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 PHONE: (626) 285-0488 EXT: LEGAL. ID: FEES PAID BUILDING ADDRESS: TR: 5904 LT: 366 5936 LOMA AV FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917801923 ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET: LONGDEN 5384-013-004 Al PERMIT ISSUANCE FEE -27.75 s THOMAS PAGE: 596 GRID: H3 LOCALITY: TEMPLE CITY, C C2 SPAS, HOT TUBS, OTHR 1.00 SPA 54.45 TENANT: - TOTAL FEES 82.20 ISSUED ON: PROCESSED BY: PLAN BY: EXPIRES ON: 05/20/05 JK' 11/16/05 OWNER: - TEL. NO: FINAL DATEFI BY: CODE: GONZALEZ LOUIS J;VICTORIA 5936 LOMA AV TEMP 917801923 DESCRIPTION OF WOR ELECTRICAL FOR SPA APPLICANT: TEL. NO: TRIPLE E LECTRICAL CONTRATORS (626) 447-5096- 2535 S. 3RD AVE SPECIAL CONDITIONS: ARCADIA, CA 91006 - CONTRACTOR: TEL. NO: APPROVALS DATE INSPECTOR SIGNATURE TRIPLE E ELECTRICAL CONT., INC. (626) 447-5096- 2535 S. THIRD AVE. LIC. NO TEMPORARY POWER POLE ARCADIA, CA 91006 410132 C10 - UNDERGROUND CONDUIT ARCHITECT OR ENGINEER: TEL. NO: UFER GROUND LIC. NO: ROUGH CONDUIT ROUGH WIRING MAIN WATER LINE PLASTIC Y/N METAL Y/N UTILITY COMPANY NOTIFIED t REPORT ID: DPR265 ROUTE TO: BS05.08