HomeMy Public PortalAbout5521 MCCULLOCH AVE_Electrical__ WORKERS'COMPENSATION DECLARATION 76A66310181'
CE-8066 APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self CE-806
Insure,
or o'certificate of Workers'.Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified copy thereof(Sec. 3800, Lab. C.)
Policy No. Company FOR APPLICANT TO FILL IN JOB �7P 4J G_
Certified co is hereby furnished.. EACH NO. FEE ADDRESS
PY Y New Residential Bldgs. 8 Pools f n
1 &2-Family,.S Ft. $ — $ LOCALITY C:
Certified copy is filed with the county building inspec- Y• q• `NEAREST
tion department. Multi-family Sq. Ft: CROSS ST. 1'�e
Residential Swimming Pools OWNER OR
Date Applicant FIRM NAME l//
CERTIFICATE OF,EXEMPTION FROM WORKERS' MAIL
COMPENSATION INSURANCE Outlets: Rec Light Sw._ ADDRESS J�tM eThis section need not be com leted if the work involved by First 20
( tip Total No. Additional CITY Tel. No.
' the permit is for one.hundred dollars-($1100).or less.)
PLAN CHECK
I certify that in the performance of the.work for which this APPLICANT
permit 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
Additional
Date.�L
Gj�,_ Total No. CITY Tel. No.
—.F3--(lt,�—Applicant
NOTICE.TO APPLICANT: If, afters making thi Certificate of Fixed Appliances Not Over 1 HP PERMIT
i Range— Heater_D.W. APPLICANT
Exemption, you should become subject to the Workers' 9
Compensation provisions of the Labor Code, you.must forth- it Oven _Dryer —W.M.— ADDRESS
with comply with such provisions or this permit shall be l Top _ FAU —W.H. —
1 2
deemed revoked. •CITY Aft Tel. IVo,Q 7
LICENSED CONTRACTORS DECLARATION Hood Fan —Other_
T Room Air.Condi REG.LICENSE Class.
I hereby affirm that I am licensed under provisions of Chapter DispREG. NUMM BER 39k<15 C'_/0(commencing with Section 7000)of Division 3 of the Business DISTRICT NO. PROCESSED BY
and Professions Code,and my license is in full force and effect.. Power Apparatus&Large Appliances
�r Size&Type HP, KW, KVA, or KVAR'
License'Number 'J!4573 Lic: Class e 'ZUp to 1 InclFINAL %P. '/�
/f �r Over 1 to 10 Incl. DATE �-®d},a ' VALIDATION
Contractor'e 1?' �G �� Date '�'❑ Over 10 to 50 Incl. b__FINAL
I am exempt under Sec. Over 50 to 100 Inc. BY _ �
B.&P.C. for this reason Over 1.00
Dater Services,Swbd.,MCC&Panelboards ►
0 -200 Amp. Under 600 V
Signature' ,; 201 - 1000 Amp. Under 600 V
E] Exemption
1000 Amp. or Over 600 V
Exemption for Reg. Maint. Elect.
SINGLE FAMILY Temp. Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit 4 4.3 A
I hereby affirm that I am exempt from the.Contractor's License Additional Sign Branch Circuits t,
r Law for the following reason (Section 7031.5, Business and 0 0 0 o 02
Professions Code):
I,, as owner of the property, will do the work and the Misc. Conduits&Conductors 0 0 3 Q 5 0
structure is not intended or offered for sale (Section Other(See Complete Fee Schedule)_ loop. _
7044, Business and Professions Code). ° ° 0 3 Q 5 0 v
CONSTRUCTION LENDING AGENCY 2 ) -83
I 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)
(Sec. 3097, Civ. C.).
PLAN CHECKING FEE
Lender's Name PERMIT ISSUING FEE p .
Lender's Address
I certify that I have read this application and state that the TOTAL FEE
300 52)
above information is correct. I agree to comply with all County
ordinances and State laws regulating Electrical wiring, and
(43
hereby uthorize represkf this County to enter upon
the. ve-m ntioned pri pection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
� 2_
Si nature of P m to Date
Q9UNTY OF LOS ANGELES TEMPLE CITY # 0508 ELECTRICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS EL 0508 0709180023
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
ILEGAL ID: I FEES PAID I BUILDING ADDRESS: 1
ITR: 13613 IT: 105 I 1 5521 MCCULLOCH AV
IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT:( TEMP CA 917802940
(ASSESSOR INFORMATION NUMBER: I I NEAREST CROSS STREET: FREER
I8573-008-004 1A1 PERMIT ISSUANCE FEE 27.75 I THOMAS PAGE: 597 GRID: C3 LOCALITY: TEMPLE CITY, Cl
I IG1 OUTLETS-LGT,SW,RECP 14.00 OUT 27.30 I
ITBNANT. G2 LIGTING+H2 RESHGRBG DISPPUITS3.00 WT 5.85 3HP 1.00 DIS 10.95 109/8/07N: PROCSSRSED BY: PLAN SY: 03/16//08EXPIES0N
1 JH4 RES RANGE HDS LT 3HP 1.00 HOO 10.95 I I
(OWNER: TEL. NO: IH7 RES EXHAUST FANS 1.00 EX 10.95 IF DATE FINAL BY: CODE: I
IRENTERIA DOMINGO;SUSANA - I TOTAL FEES 93.75I I
15521 MCCULLOCH AV I I I
ITEMP 917802940 1 IDESCRIPTION OF WORK
I (ELECTRICAL FOR ADDITION AND KITCHEN REMODEL
(APPLICANT: TEL. NO: I I I
IJR GENERAL BUILDER (626) 672-5457- 1 I 1
15221 FLORINDA AVE I ISPECIAL CONDITIONS: 1
TEMPLE CITY CA 91780 I I
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(CONTRACTOR: TEL. NO: (APPROVALS DATE INSPECTOR SIGNATURE I
IJR. GENERAL BUILDERS (626) 672-5457- I 1 I
15221 FLORINDA AVE LIC. NO I ITEMPORARY POWER POLE I I I
ITEMPLE CITY CA 91780 747128 B I I I I I
1 1 (UNDERGROUND CONDUIT I I 1
(ARCHITECT OR ENGINEER: TEL. NO: I 1UFER GROUND 1 I I
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LIC. NO: I IROIIGH CONDUIT I I
IROUGH WIRING (W'
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IMAIN WATER LINE uI
PLASTIC YIN METAL YIN I I I
I (UTILITY COMPANY NOTIFIEDI I 1
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(REPORT ID: DPR265 ROUTE TO: BS0508 I I 1
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