HomeMy Public PortalAbout10455 LOWER AZUSA RD_Electrical__ WORKER S'COMPENSATION DECLARATION CE-806G (2-80)
CEAPPLICATION FOR ELECTRICAL PERMIT
E-806
I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY
insure, or a certificate of Workers'Compensation Insurance,orGv'
a certified copy thereof(Sec. 3800,Lab.C.)
fjr 3FOR APPLICANT TO FILL IN JOB j
, `Company E -'� EACH NO. FEE
Policy N12ADDRESS iJ
New Residential Bldgs.&Pools E �` �Q�k7►
Certified copy is hereby furnished. 1&-2,Family,Sq. Ft. $ — $ LOCALITY }
El
Multi-family Sq. Ft. — NEAREST v
Certified copy is filed with the county building inspection CROSS ST '
department. Residential Swimming Pools OWNER OR f ��
a FIRM NAME Q etr.s /sy/�li/
Date Applicant ' r -��' 'L� f' MAIL
Outlets: Rec. fight_First
46 ADDRESS .,) � -�
First 20
CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. Additional CITY Tel No. 2
COMPENSATION INSURANCE }
PLAN CHEC d
(This' section need not be completed if the work involved APPLICANT 0
by the permit is for one hundred dollars ($100) or less.) Lighting Fixtures First 20 ADDRESS U
Total No. Additional
I certify that in the performance of the work for which this Fixed Appliances Not Over 1 HP CITY Tel No. 0
permit is issued, I shall not employ any person in any manner PERMIT a r, r ) O
so as to become subject to the Workers' Compensation Laws. Range_ Heater_D.W. APPLICANT iL W
Oven _ Dryer_W.M. ADDRESS • Jr f. �,
no
Date Applicant Top.' _ FAU _W.H.. Z
Hood _ Fan _Other_ CITY vr,A- Tel No.
NOTICE TO APPLICANT: If, after making this Certificate of Disp. _ Room Air Cond._ LICENSE OR
Exemption, you should become subject to the Workers' REG. NUMBER 31 I Clas
., s
Compensation provisions of the Labor Code, you must forth- Power Apparatus& Large Appliances DISTRICT NO. PROCE SED-BY
with comply with such provisions or this permit shall be Size&Type HP,KW, KVA,or KVAR 5.1 W
deemed revoked.
Up to 1 Incl.
FINAL
Over 1 to 10 Incl. DATE
LICENSED CONTRACTORS DECLARATION `( �j VALIDATION
Over 10 to 50 Incl.
I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. FINAL
9 commencin with Section 7000 of Division 3 of the Busi- BY
( g' ) Over 100 �..J`
ness and Prof essions.Code, and my license is in full force and
effect. Services
,License Number 3- Lic.Class C—/,o 0-200 Amp. Under 600 JV 4,
201-1000 Amp. Under 600 Vt�tt`
Contractor Date ` Over 1000 Amp.or Over 600 V
HOME OWNER-BUILDER DECLARATION Temp. Power.Pole&Appurtenances
I hereby affirm that I am exempt from the Contractor's Sign with One Branch Circuit
License Law for the following reason (Section 7031.5, Busi- Additional Sign Branch Circuits
ness and Professions Code): o
Misc.Conduits&Conductors z 3,1 3.21A
F] I, as owner of the property, will do the work and the Other (See Complete Fee Schedule)— # o o.o o"0 2.
structure is not intended or offered for sale (Section ;
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY .2;0 °
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit- is PERMIT FEE (Sub-Total) 2 1,5 O
issued (Sec. 3097,Civ.C.). ,
Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee) 'I 1.2 1 -80
Lender's Address PERMIT ISSUING FEE
I certify that I have read this application and state that the TOTAL FEE
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
i ure of Perrr Wtee Date
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 ELECTRICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS EL 0508 0103010022 ,
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
LEGAL ID: FEES PAID BUILDING ADDRESS:
TR: 13645 LT: 80 BL: .001 UN: .002 10455 LOWER AZUSA RD
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917803470
ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET: HALIMAX
8585-017-021 Al PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 597 GRID: C5 LOCALITY: TEMPLE CITY
K1 SIGNS, OUTLINE LGT 1.00 SIG 38.85
TENANT: TOTAL FEES 66.60 ISSUED ON: PROCESSED BY: PLAN BY: EXPIRES ON:
03/01/01 LS 08/28/01
OWNER: TEL. NO: FINAL TE FINAL BY: CODE:
FRIENDLY DENTAL CARE (MAFAR) G,t
3875 WILSHIRE BLVD `
DESCRI TION F WORK
2-SIDE POLE SIGN W/ELE AL
APPLICANT: TEL. NO:
ALONSO (909) 986-4195-
1057 E G ST SPECIAL CONDITIONS:
ONTARIO CA 91764
CONTRACTOR: TEL. NO: APPROVALS DATE INSPECTOR SIGNATURE
AL'S SIGNS (909) 986-4195-
1057 E. G ST. LIC. NO TEMPORARY POWER POLE
ONTARIO CA 91764 643282,C45
UNDERGROUND CONDUIT O� 7IL1.
0
ARCHITECT OR ENGINEER: TEL. NO: UFER GROUND
-±-Y
ja/
LIC. NO: ROUGH CONDUIT 1
ROUGH WIRING
MAIN WATER LINE
PLASTIC Y/N METAL Y/N
UTILITY COMPANY NOTIFIED
REPORT ID: DPR265 ROUTE TO: SS0508