HomeMy Public PortalAbout9363 LOWER AZUSA RD_Electrical__ WORKERS'COMPENSATION DECLARATION �1 31 3/87 APPLICATION FOR ELECTRICAL PERMIT
1 hereby affirm that" fiave,a certificate of consent to self ;CE:eObG
insure, or a certificate of Workers'Corripensgtioii Insurance,, ' COUNTY OF LOS ANGELES ' DEPT. OF PUBLIC WORKS
or a certified copy thereof(Sec. 3800,.Lab. C.
Policy No.�3 3% ompany � FOR APPLICANT TO FILL IN JOB it JIV Rl'
❑Certified copy is hereby nis . d Nevi Residential Bldgs. &Pools EACH NO. FEE �p
ADDRESS, 3 Lclt:letZ SA
❑Certifi"c�is filed a county building inspec- 1 8 2-Family, Sq. Ft. . $ = $ LOCALITY
tion rtment. AVUlti-family Sq. Ft. NEAREST]
Residential Swimming Pools OWN CRORS
Tk
Date Applicant OR �.
OI _
.. ts: RecLight �Sw.
CERTIFICATE'OF EXEMPTION FROM WORKERS' Out' � FIRM NAME MAIL
COMPENSATION INSURANCE ADDRESS! Q./ S6 Lt�hd e.
First 20
(This section need not be completed if the work involved by Total No.g ,) Additional CITY j 9� Alytp Tel. No:
the permit is for one hundred dollars($100)or less.) PLAN CHECK
I certify that in the performance of the work for which this I - APPLICANT
permit is issued,I shall not employ any person in any manner I ' i
Additti
so as to become subject to the Workers'Compensation Laws. Lighting Fixtures First ADDRESS
' � onal
Tdtal No. CITY Tel. No.
Date Applicant Fixed Appliances Not Over 1 HP PERMIT p
NOTICE TO APPLICANT: If, .after making 'this Certificate'of �/ APPLICATION 3-C-- C
Exemption, you should become subject to the. Workers' Range— Heater=D.W.
Compensation provisions of the Labor Code, you must forth- Oven — Dryer W.M. ADDRESS 3G 0 �� S s � 6
with .comply with such provisions or this permit shall be Top ALI °fW.H.
deemed revoked. Hood Fan -Other— CITY ° Tel. No?, -Frs-7ast
LICENSED CONTRACTORS DECLARATION I LICENSE OR
_ — ,
I hereby affirm,that I am licensed under provisions of Chapter 9 DiI p. Room Air Cond. REG. NUMBER Sy W Class. -jO
(commencing with Section'7000)of Division 3 of the Business Pow r Apparatus$Large Appliances DISTRICT NO. PCESSE Y >-
and Professions Code,and my license is in full force and effect. IZ
``
Size&Type HP, KW, KVA, or KVAR i p
License Number T Lic. Class_!G -10 Up to 1 Incl. FINAL 51 J' V
r f Over 1 to 10 Incl. DATE VALIDATION 0
Contractor ._ • Date. F Over 10 to 50 Incl. FINAL ' O
❑ I am exempt under Sec. ; Over 50.to 100 Inc. BY I W
a
B.&P.C. for this reason I Over 100 LU
Services, Swbd., MCC'&Panelboards ® Z
Date.. 0•200 Amp. Under 600 V
Signature 2 1 - 1000 Amp. Under 600 V
❑ O er 1000 Amp. or Over 600 V
Exemption for Reg. Maint. Elect. :I
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Temp. Power Pole 8 Appurtenances
Si with One Branch Circuit s
I hereby affirm that I.am exempt from the Contractor's License g� ACCT.4
Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits ,
Professions Code): + 3,207 116°00
Ell, as owner of the property, wiJI 'do the work and the Misc. Conduits&Conductors 4 ITEMS
structureis not intended or offered for sale(Section 7044, Oth r(See Complete Fee Schedule)— TOTAL 106
Business and Professions Code).
CONSTRUCTION LENDING AGENCY CHECK
1 hereby affirm that there is a construction lending.agency for
the performance of the work'for which this.permit.is:issued PERMIT FEE (Sub-Total) CHANGE °
(Sec. 3097, Civ. C.).
PLAT CHECKING FEE
Lender's Name 0000-0001 5/ 3/90
PE IT ISSUING FEE °
Lender's Address
11487 1 Aid 10.4
I certify that I have read this application and state that the TOT kL FEE
above information is correct. I agree to comply with all County s
i ordinances and State laws regulating Electrical wiring, and
hereby authorize representative"f this County to enter upon
the abo mentionpr ert r inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
®6
Si lure c&Permittee Date
COUNTY OF LOS ANGELES TEMPLE CITY # 0505 ELECTRICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS EL 0508 0605160013
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
LEGAL ID: FEES PAID BUILDING ADDRESS:
BX: 228 PG: 04 PC: 2 9363 LOWER AZUSA RD
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917804218
ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET: TEMPLE CITY
8590-024-029 Al PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 596 GRID: JS LOCALITY: TEMPLE CITY, C
G1 OUTLETS-LGT,SW,RECP 5.00 OUT 9.75
TENANT: G2 LIGHTING FIXTURES 1.00 LGT 1.95 ISSUED ON: PROCESSED BY: PLAN BY: EXPIRES ON:
TOTAL FEES 39.45 05/16/06 JK 11/12/06
OWNER: TEL. NO: F7}1 DAT FINAL BY: CODE:
YU, CHRISTINA (626) 285-1095- (/�,
9363 LOWER AZUSA RD
TEMP 917804218 DESCRIPTION OF WORK
4 OUTLETS, 1 SWITCH AND 1 LIGHT FIXTURE
APPLICANT: TEL. NO:
SAME AS OWNER -
SPECIAL CONDITIONS:
CONTRACTOR: TEL. NO: APPROVALS DATE INSPECTOR SIGNATURE
SAME AS OWNER -
LIC. NO TEMPORARY POWER POLE
UNDERGROUND CONDUIT
ARCHITECT OR ENGINEER: TEL. NO: LIFER GROUND
LIC. NO: ROUGH CONDUIT
ROUGH WIRING
MAIN WATER LINE
PLASTIC Y/N METAL Y/N
UTILITY COMPANY NOTIFIED
REPORT ID: DPR265 ROUTE TO: BS0508