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HomeMy Public PortalAbout6235 LOMA AVE_Electrical__ ..�\' WORKERS'COMPENSATION DECLARATION CE-863 10/81 APPLICATION FOR ELECTRICAL PERK41T I y(firm that I have a certificate of consent to self insure, CE-806G or yte of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY cop (Sec.3800,Lab. C.) Policy NL. Company FOR APPLICANT TO FILL IN JOB ❑ Certified copy is herebyfurnished. EACH NO. FEE ADDRESS, New Residential Bldgs. &Pools ❑ Certified copy is filed with the county building inspection 1 & 2-Family,Sq.Ft. $ — $ LOCALITY �ip�� department. Multi-family Sq.Ft. — NEAREST CROSS S, . G� Date Applicant Residential Swimming Pools OWNER OR j J FIRM NAME ..5�L / L ox p6– S' CERTIFICATE OF EXEMPTION FROM WORKERS' MAIL q COMPENSATION INSURANCE Outlets:Rec— Light Sw. — ADDRESS 4.23 > (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 T����©�, I certify that in the performance of the work for which this permit PLAN CHECK C� 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 � � Total No. Date �� u� Applican Additional CITY Tel.No.Fixed Appliances Not Over 1 HP NOTICE TO APPLICANT: If, after making this Certificate of PERMIT Exemption,you should become subject to the Workers'Compensation Range_ Heater— D.W. — APPLICANTS provisions of the Labor Code, you must forthwith comply with such Oven _ Dryer _ W.M. _ ADDRESS provisions or this permit shall be deemed revoked. Top — FAU _ W.H. LICENSED CONTRACTORS DECLARATION Hood — Fan — Other_ CITY I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. EG.N OR R (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. Power Apparatus& Large Appliances DISTRICTNO PROCESSEP BY Size& Type HP,KW,KVA,or KVAR , 0 License Number Lic.Class Up to 1 Incl. FINAL q Over 1 to 10 Incl. DATE —Se/ Ir Contractor Date F © VALIDATION C0 ❑ Over 10 to 50 Incl. INAL I am exempt under Sec. Over 50 to 100 Inc. BYIII � 0.B.&P.C.for this reason Over 100 � Services,Swbd.,MCC & Panelboards Date: 0- 200 Amp.Under 600 V t 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 2 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 •4LYo�� Code): 25.50 Mist. Conduits& Conductors I,as owner of the property,will do the work and the structure "" """"""" ' OtherSee Cam lete Fee Schedule is not intended or offered for sale (Section 7044, Business ( p ) " and Professions Code). TOTAL 2!5.a!50 CONSTRUCTION LENDING AGENCY OEM 25• I hereby affirm that there is a construction lending agency for the / Mf �A performance of the work for which this permit is issued(Sec.3097, PERMIT FEE (Sub-Total) ........ . PLAN CHECKING FEE Lender's Name i C/?Ase�e PERMIT ISSUING FEE t +J� /�T Lender's Address / 3616 1 M11139 I 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 property for inspection purposes. i SEE REVERSE FOR EXPLANATORY LANGUAGE 01 Date Signature of Permittee COUNTY OF LOS ANGELES TEMPLE CITY # 0508 ELECTRICAL PERMIT DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS EL 0508 0503080015 BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 PHONE: (626) 285-0488 EXT: --LEGAL D: FEES PAID BUIL ING ADDRESS: TR: 5904 LT: 245 6235 LOMA AV FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917801635 ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET: 5384-009-021 Al PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 596 GRID: H2 LOCALITY: TEMPLE CITY, C HA FAU LESS 3HP 1.00 FAU 10.95 TENANT: JA HEAT PUMPS +3-10HP 1.00 HT 19.65 ISSUED ON: PROCESSED BY: PLAN BY: EXPIRES ON: TOTAL FEES 58.35 03/08/05 JK 09/04/05 OWNER: TEL. NO: Ir FINAL BY: CODE: FLORES SALVADOR L;SOCORRO M (626) 286-5895- 6237 LOMA AV I:XPMEu' TEMP 917801635 DESCRIPTION OF WORK ELECTRICAL FOR AIR CONDITIONING AND HEATING SYSTEM APPLICANT: TEL. NO: PEREZ (323) 727-0266- 6634 SOUTHSIDE DR SPECIAL CONDITIONS: LOS ANGELES CA 90022 CONTRACTOR: TEL. NO: APPROVALS DATE INSPECTOR SIGNATURE CALIFORNIA INSTALLERS (323) 727-0266- 6634 SOUTH SIDE DRIVE LIC. NO TEMPORARY POWER POLE LOS ANGELES, CA 90022 651597C20 UNDERGROUND CONDUIT ARCHITECT OR ENGINEER: TEL. NO: llF€f GROUND LIC. NO: ROUGH CONDUIT ROUGH WIRING MAIN! WATER LINE PLASTIC Y/N METAL Y/N UTILITY COMPANY NOTIFIED * ADDITIONAL DATA ON FILE REPORT ID: DPR265 ROUTE TO: BS0508