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WORKER'S COMPENSATION DECLARATION 20.0019 DPW(19-91)
78A863 APPLICATION FOR ELECTRICAL PERMIT
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I h eby"awretn that I have a certificate of consent to self insure,
or certificate of Worker's Compensation Insurance, or a cer'ied COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS BUILDING AND SAFETY DIV.
cop Rhereof( ec:,3800 Lab,•Cr)
Policy /,
No2�16J. Company FOR APPLICANT TO FILL IN JOB (� Q ^
ILEI ADDRESS T :3
Certified copy is hereby furnished. �'���'
New Residential Bldgs.&Pools JN�0, EACH FEE LOCALITY
1&2-Family,Sq.Ft. $. $
Certified copy,i's filed with.the.county building inspection NEAREST
departmrent. Multi-family'Sq.Ft. CROSS ST. yDate --0Applicant&duUP1 �J�g1?ajoResidential Swimming Pools MAP SSSOK �3a Z PAGE��0 PARCEL/CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Ric Light Sw.�1 �M NAMECOMPENSATIONINSURANCE U 1AFirst 20 ' MAIL
(This secfion need.not be completed If the work In..volved by the Total No.� Additional +'�� � ADDRESSpermit Is for one hundred dollars(5700)or-loss.)I certify that in the performance of the work for which this permit CITY. Tel.No.
ft
is.Issued, I shall not employ any person in any manner so as to• pobecome;subject to the Workers'Compensation Laws. Lighting.Fixtures First 20 'o APPLICANT K
e Total No. Additional ADDRESS
Date . ` Applicant'SM 14(/� • 0,40.#110 RESIDENTIAL APPLIANCES NOT OVER 3 HP.
NOTI 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 Libor Code_,you must forthwith comply with such PERMIT
provisions or this permit shall be deemed revoked. Power Apparatus&Large Appliances APPLICANT 144,4 ItVel eAR1Wk6
LICENSED CONTRACTORS DECLARATION Size&Type HP,,s ,KVA,or KVAR p ` ADDRESS z 99 L4
I hereby'affirm that I am licensed under provisions of Chapter 9 'liver 3 to 10 Incl. �o �
(commencing with Section 7000)of Division 3 of the Business and CITY C') T.I.No.. '•4VTY
Professions Code,and my license Is in full:force and effect. Over 10 to 50 Incl.
�j,1 1
Oyer 50 to 100 Incl. RIEG.CENSE NUMBER
Class. d
License Number y / 1 2 / 9 Llc.Class Over 700 DISTRICT NO. P SSED BY U
J /� Se i e S d.,M C&Panel rds � � �s
Contractor I"A.1409 92&Z�1B Date; '`F— � '1-399 p. 0 / . FINAL p
❑ DATE
I am exempt under Sec.. 400-7000 Amp..Under 600 V + VALIDATION V
Over 1000 Amp.or Over 600 V FINAL a
B:&P.C.for this reasonBY
BRANCH CIRCUIT FEES (q
Date: 15A,or 20A,120V,Lighting or Recept. Z
1 To 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
HOME OWNER-BUILDER DECLARATION it h Ci
B
with One Branch Circuit �' 'i
I hereby affirm that I am exempt from the Contractor's License Law Sign w 'jk; _Or
for the following reason(Section 7031.5, Business and Professions Additional Sign Branch Circuits
Code):
❑ — ,
1,as owner of the property,will do the work and the structure Misc..Conduits&Conductors 3 I F-111
is not intended or offered for sale(Section.7044, Business Other(See Complete Fee Schedule) 'r5 0
.and Professions Code). 10 4 HL " 00
CONSTRUCTION LENDING AGENCY CHECK 15[1.00
I hereby affirm that there is a construction lending agency for the CHANGE .1313
performance of the work for which this permit is Issued(Sec. 3097, PERMIT FEE (Sub-Total) a 3
Civ.C.)
y i S .� PLAN CHECKING FEE a� r� �� ) f� � f 9,t
Lender's Name !,
"1
Lender's Address• spdn dg" 1/r PERMIT ISSUING FEE 460,4 1 A)1 9:34
Q, � 3 � Lo s•
1 certify that I have read this application and under penalty of purjury state TOTAL FEE
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
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 ELECTRICAL PERMIT
DEPARTMENT OF%PUBLIC WORKS 9701 LAS TUNAS EL 0508 0901070001
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
ILEGAL ID: I FEES PAID I BUILDING ADDRESS: I
ON FILE I 1 9431 LONGDEN AV
IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT:1 TEMP CA 917801609
(ASSESSOR INFORMATION NUMBER: I I NEAREST CROSS STREET: OAK
15382-020-047 IAl PERMIT ISSUANCE FEE 27.75 I THOMAS PAGE: 596 GRID: J2 LOCALITY: TEMPLE CITY, Cl
I IG1 OUTLETS-LGT,SW,RECP 52.00 OUT 82.20 1
ITENANT: IG2 LIGHTING FIXTURES 50.00 LGT 79.50 ISSUED ON: PROCESSED BY: PLAN BY: EXPIRES ON:
IHA FAD LESS 3HP 2.00 FAD 21.90 01/07/09 SR 07/06/09
I IH1 RES ELEC OVEN LT 3HP 1.00 OVE 10.95 1
(OWNER: TEL. NO: JH2 RES GRBG DISP LT 3HP 1.00 DIS 10.95 IF AL DATE FINAL BY: CODE: I
ISUN TZYH DER (626) 292-6979- JH3 RES DISHWASHR LT 3HP 1.00 DIS 10.95 1 I
19431 LONGDEN AV IH4 RES RANGE HDS LT 3HP 1.00 HOO 10.95 ftl 1
ITEMP 917801609 IH5 RES WASH MACH LT 3HP 1.00 WAS 10.95 ID CRI TiOF WORK 1
IJB AC UNITS +3-10HP 2.00 AC 39.30 (ELECTRICAL FOR ADDITION, DEL AND UPGRADE SERVICE PANEL I
I ILB 200 AMP PANELS, MCC 1.00 PAN 38.85 ITO 200 AMP I
(APPLICANT: TEL. NO: 1 TOTAL FEES 344.25 1 I
IZ. SUN & ASSOC. INC. (626) 705-2210- I I I
18653 GARVEY AVE. I ISPECIAL CONDITIONS: 1
IROSEMEAD CA 91770 I I I
ICONTRACTOR: TEL. NO: 1 (APPROVALS DATE INSPECTOR SIGNATURE 1
ITZYH-DER SUN (626) 705-2210- I 1 I
ISHANNON S MA LIC. NO 1 ITEMPORARY POWER POLE I I I
19431 LONGDEN AVENUE NONE I I I I I
ITEMPLE CITY, CA 91780 1 (UNDERGROUND CONDUIT I I I
(ARCHITECT OR ENGINEER: TEL. NO: 1 IUFER GROUND I I I
IZ. SUN AND ASSOCIATES, INC. (626) 705-2210- I 1 1 1 I
18653 GARVEY AVE #204 LIC. NO: I IROUGH CONDUIT I I I
IROSEMEAD, CA 91770 C19992 I I I
I I IROIIGH WIRING 1{
1 ]MAIN WATER LINE
IPLASTIC YIN METAL YIN I I I
I (UTILITY COMPANY NOTIFIEDI I I
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IREPORT ID: DPR265 ROUTE TO: BS0508 I I I I
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