HomeMy Public PortalAbout6219 LOMA AVE_Electrical__ WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12-91) APPUCA 0 MN FOR EL�E11�TMICAL� PERNT
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I hereby at that I have a certificate of consent to self insure, 76A663
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.) Q
Policy No. Company FOR APPLICANT TO FILL IN JOB
ADDRESS /
Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE LOCALITY ��✓� jo L
_
Certified copy is filed with the county building inspection 1 &2-Family,Sq.Ft. $ $ NEAREST
de artment. �_ Multi-family Sq.Ft. CROSS ST. 1q2 Z. D
Dat Applicant Residential Swimming Pools ASSESSOR
MAP BOOK PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER OR
COMPENSATION INSURANCE Outlets:Rea_Light Sw. FIRM NAME n--,
First 20 AhAIL
(This section need not be completed if the work involved by the ADDRESS
permit'is for one hundred dollars'($100)or less.) Total No. Additional
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 t0 . PLAN CHECK
become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 APPLICANT
Total No. Additional
ADDRESS
Date S� ^ Applicant 's * 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 suchPERMIT
provisions or this permit shall be deemed.revoked. Power Apparatus'&Large Appliances APPLICANT AQIf44
LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS 2Ur-�
I hereby affirm that I am licensed under provisions of Chapter 9 Over 3 to 10 Incl. /� �
CITY q L �, Tel.No.7—
Professions
with Section 7000) of Division 3 of the Business and �Q
Professions Code,and my license is in full force and effect. Over 10 to 50 Incl. }
Over 50 t0 100 Incl. REGNNUM ER LICESE OR2oZ Class. d
Over 100 DISTRICT NO. R SSED BY O
License Number1 �� Lic.Class V
Services,Swbd.,MCC eanelb a� rds ,a 11
• > 0-399 Am �n'ddeer 6600 VFINAL O
Contractor `� Date DATE H
❑ 400-1000 Amp.Under 600 V q' 3 VALIDATION V
I am exempt under Sec. W
Over 1000 Amp.or Over 600 V - FINAL - d
— B.&P.C.for this reason BRANCH CIRCUIT FEES BY4)�
U)
Date: 15 ,or 20A�ghting or Recept. j Z
o 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 s
HOME OWNER-BUILDER DECLARATIONq
I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit A" �a
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits
Code): ��-
❑. { TTSSJ
I, as owner of the property,will do the work and the structure Misc.Conduits&Conductors 3 i.I
is not-intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) D TOTAL .77 70
and Professions Code).
CHECK 77.70
CONSTRUCTION LENDING AGENCY _
I hereby affirm that there is a construction lending agency for the !: H !ht
performance of the work for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total)
Civ.C.)
PLAN CHECKING FEE
Lender's Name 000 lP001 c/ _6F! 3
PERMIT ISSUING FEE �c�r 957_ I A rlI 1!_10
Lender's Address TOTAL FEE ry
I certify that I have read this application and under penalty of purjury state /r
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
for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE OF PERMITTEE DATE
- -UCATMN- FOR
APP
76A689-Cfi806'-]1-5 i
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION ADDRESS.,I
JOHN A. LAMBIE, County Engineer
• CASSATT D.'GRIFFIN, Sup't of Building ALITY
REST
tt FOR APPLICANT TO FILL IN CROSS ST. ��r " C✓�, ``.�
PERNIIT• FEES
• ITEM NUMBER $EACH $ �{FEE OWNER .
WNER
MAIL
OLE7 CEPTJJSWJy ADDRESS GHT. s?
LIGHTING FIXTURESf0 r " `-' - -.:_
CITY. _ � TEL:ANO. '
o. ELEC.RANGES' 'CLO DRYERS'.' • - t' -
ELECTRICIAN 44 l`.I C t_ L•.i ,
WATER HEATERS .50 / •y / -
ELEC.SPACE HTRST .DISHWASHERS -�'�n"'�'""' ADDRESS (;-__. ,r�F'` /, ., �✓ �:
. h ;.r @ CITY i'� 2 �/-': +? TEL NO
GARBAGE DISP•=OSRAUTO a i _
Ea .r.'I"-`x�,..•ty:.. �,M. -s I STATE '' - s .. -.•� - -
'�WZ1fiHERb+.�-`8TA'•CQpKING.UNI'Ik3 ♦+ ::'1,. .25 LICENSE NO.' r-
MOTORS: OVER INC.
�- O,— 1/2 25 DISTRICT O. G OUP LONE READYjFOR XMSPECTICbN
9 50
"2 —..'S 1.00
"INSPECTION RECORD
5 — 15 1.50
15 — 'S0 2.50
50—,200 5.00
SIGNS:, N rTRANS.
F) NO.LAMPS -
SERVICE 0-600V 1.00 ° C2 "
SERVICE.OVER 600V- 5.00
MISC:
WIRING PERMIT " 1.00 (?
r FIXTURE PERMIT 1.00 )U '
SUPPLEMENTARY PERM IT k'. r17.
50' };'
`.
TOTAL FEE g f, n APPROVALS
i, I•HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION _ DATE INSPECTOR'S SIGNATURE
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY it CONDUIT
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
1 ELECTRICAL WIRING. A WIRING
I HEREBY CERTIFY THAT, 1 AM PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED.BY "LOSANGELES COUNTY AND STATE OF FIXTURES '
i CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE POWER`
„ DESCRIBED RESIDENTIAL PROPERTY.
SOF PERM EF --,7 '" - _. UTILITY CO.NOTIFIED
�. �' •a FINAL
LFVLIDATION ARTH U R C.VEIT,
' ,�Mo" cwsH• SUPERVISING ELECTRICAL ENGINEER
,
f
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 ELECTRICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS EL 0508 9905250001
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
LEGAL ID: FEES PAID BUILDING ADDRESS:
TR: 5904 LT: 247 6219 LOMA AV
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917801635
ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET: LONGDEN
5384-009-023 Al PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 596 GRID: H2 LOCALITY: TEMPLE CITY
HA FAU LESS 3HP 1.00 FAU 10.80
TENANT: JB AC UNITS +3-10HP 1.00 AC 19.80 ISSUED ON: PROCESSED BY: PLAN BY: EXPIRES ON:
TOTAL FEES 58.35 05/25/99 UT 11/21/99
OWNER: TEL. NO: FINAL DATE FINAL CODE:
GAY EDWIN K;ARDIS G
444 NAOM I AV _
ARCD 910077310 DESCRIPTION OF WOR
ELECTRICAL FOR NEW HVAC SYSTEM
APPLICANT: TEL. N0:
AIR CONTROL OF CALIFORNIA (909) 393-3099-
2762 AVE. MARGUERITE SPECIAL CONDITIONS:
CHINO HILLS,CA .
CONTRACTOR: TEL. NO: �� f� APPROVALS DATE INSPECTOR SIGNATURE
AIR CONTROL OF CALIFORNIA (909) 393-3099— Qi
2762 AVENIDA MARGUERITE LIC. NO TEMPORARY POWER POLE
CHINO HILLS, CA 91709 540986C20 UNDERGROUND CONDUIT
s' ARCHITECT OR ENGINEER: TEL. N0: // i UFER GROUND
//r
LIC. NO:rrIll _ lllllll ROUGH CONDUIT
ROUGH WIRING
MAIN WATER LINE '
K J PLASTIC Y/N. METAL"Y/N
TILITY COMPANY NOTIFIED
REPORT ID: DPR265 ROUTE TO: BS0508