HomeMy Public PortalAbout5817 MYDA AVE_Electrical__ ,W'ORKER'S COMPENSATION DECLARATION 76A669 DPW 9189 APPLICATION ICATION FOR ELECTRICAL PERMIT
I hereby e5firm�7hat I have a certificate of consent to self insure, 76A663 f''i L V ®Y
or ccfFficate of Worker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS BUILDING AND SAFETY DIV.
copy thereof(Sec.3800 Lab.C.)
Policy No.NO. �- y Company !; FOR APPLICANT TO FILL IN JOB /]a
ADDRESS
EACH NO. FEE
�Certifled copy is hereby furnished. New Residential Bldgs.&Pools LOCALITY
Certified copy is filed with the county niln4lon 1&2-Family,Sq.Ft. $ — $
depa t. Multi-family Sq.Ft. — CROSS ST.
Date Applicantr Residential Swimming Pools ASSESSOR
MAP BOOK PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec._Li ht Sw. OWNER OR
COMPENSATION INSURANCE g First 20 FIRM NAME •14
(This section need not be completed If the work Involved by the MAIL /
permit Is for one hundred dollars($100)or lose.) Total No. Additional ADDRESS f
I certify that in the performance of the work for which this permit CITYTel.No.
is issued, I shall not employ any person in any manner so as to I PLAN CHE
CL
become subject to the Workers'Compepsation Laws. Lighting Fixtures First 20 APPLICANT
Total No. Additional
ADDRESS
Date Applicant 15 OR 20A,120V BRANCH CIRCUITS
NOTICE TO APPLICANT: If, after making this Certificate of CITY Tel.No.
Exemption,you should become subject to the Workers'Compensation 1 TO 10 INCLUSIVE EACH
provisions of the Labor Code,you must forthwith comply with such 11 TO 40 INCLUSIVE EACH PERMIT
provisions or this permit shall be deemed revoked. 41 OR MORE BRANCH CIRCUITS EACH APPLICANT �
LICENSED CONTRACTORS DECLARATION ADDRESSZA
I hereby affirm that I am licensed under provisions of Chapter 9 15 OR 20A,208V TO 277V LIGHTING EACH D J
(commencing with Section 7000)of Division 3 of the Business and CITY Tel.No. ,��l C
Professions Code,and my license is in full force and effect. RESIDENTIAL APPLIANCES UP TO 3HP LICENSE OR y
a -7 Z. class. C 16 C
�//' Power Apparatus&Large Appliances REG.NUMBER ,�
License Number Lic.Class.
v Size Type HP,KW,KVA,or KVAR DISTRICT NO. ! f/ P ED BY 1.
Up to 3 Incl. O L6!c
Contractor Date 2 r �-- Over 3 to 10 Incl. DA7E U
Over 10 to 50 Incl. 0Q
❑ I am exempt under Sec. Over 50 to 100 Incl. U — /2 VALIDATION G
Over 100 FINAL
B.&P.C.for this reason BY
Services,Swbd.,MCC&Panelboards
Date: 0-200 Amp.Under 600 V
Signature 201-1000 Amp.Under 600 V
❑ Exemption for Reg.Maim.Elect. Over 1000 Amp.or Over 600 V •-t
i
SINGLE FAMILY Temp.Power Pole&Appurtenances -w a
HOME OWNER-BUILDER DECLARATION ACCTA
I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit �7 nr•t•7
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits r730 34.4---
Code):
4.4=Code):
Eli ITEti
I,as owner of the property,will do the work and the structure Misc.Conduits&Conductors ty n�
is not intended or offered for sale(Section 7044, Business Other(See Complete Fee Schedule) TOTAL 34.43
and Professions Code). CHEM
CONSTRUCTION LENDING AGENCY ��� {.� oCl-1
I hereby affirm that there Is a construction lending agency for the
performance of the work for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total)
Civ.C.)
PLAN CHECKING FEE OCCO-0001 8/25/9
Lender's Name
PERMIT ISSUING FEE 7 1
Lender's Address TOTAL FEE �4 :- G r 't
I certify that I have read this application and state 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 fc %!on urposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
IG ATURE APA.
E
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 ELECTRICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS EL 0508 0404150030
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
LEGAL ID: S PAI LDIN DDR S
TR: 5905 LT: 122 5817 MYDA AV
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917801824
AS
SS INFORMATION N M ER: NEAREST CROSS STREET: ROSEMEAD BLVD.
5387-014-019 Al PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 596 GRID: H3 LOCALITY: TEMPLE CITY, C
G1 OUTLETS-LGT,SW,RECP 36.00 OUT 60.60
TENANT: G2 LIGHTING FIXTURES 10.00 LGT 19.50 ISSUED ON: PROCESSED BY: PLAN BY: EXPIRES ON:
H7 RES EXHAUST FANS 1.00 EX 10.95 04/15/04 VG 10/12/04
TOTAL FEES 118.80
OWNER: TEL. NO: FINA E FINAL BY. CODE:
LIU, HUATANG (626) 309-5062-
5817 MYDA AV
TEMP 917801824 DE C IPTIO F WORK
ELECTRICAL FOR ADDITION
APPLICANT: TEL. NO:
NG (626) 215-2212-
9515 E. CAMINO REAL SPECIAL CONDITIONS:
ARCADIA, CA 91007
CONTRACTOR: TEL. NO: APPROVALS DATE INSPECTOR SIGNATURE
LIU, HUATANG (626) 215-2212-
5817 MYDA ST. LIC. NO TEMPORARY POWER POLE
TEMPLE CITY, CA 91780 NONE
UNDERGROUND CONDUIT
ARCHITECT OR ENGINEER: TEL. NO: UF5R GROUND
ORIENTAL CONSTRUCTION CO. (626) 215-2212-
9515 E. CAMINO REAL LIC. NO: ROUGH CONDUIT
ARCADIA, CA 91007 NONE
ROUGH WIRING
MAIN WATER LINE
PLASTIC Y/N METAL Y/N
UTILATY COMPANY OTI E
�I
REPORT ID: DPR265 ROUTE TO: BS0508
COUNTY OF LOS ANGELES TEMPLE CIT': r;:
` DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS ^L%%iiclrgL 'PERMIT
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 ri CS03 0407120015
PHONE: (626) 235-0488 EXT:
LEGAL ID: ---
-T-
?R: 5905 LT: 722 e D G ADDRESS:
FEE DESCRIPTION: 5817 MYDA AV
78
ASSESSOR NFORMA IO ;lt;••3E•,; -QUANTITY: UOM: 1t�10UNT;I TEMP CA 917801$24
5387-014-019 _ r1 PERMIT ISSUANCE FEE �, i NEAREST CROSS STREET: ROSEMEAD BLVD.
27.,, THOMAS PAGE-: 5,76 GRID: H3 LOCALIT": TEMPLE CIT)
TENANT: — !LA 100 AMP PANELS, MCC 1.00 PAN -=.85
TOTAL FEES "W-60 FlEI7 _/04 TS—S DON: PROC- SE—0f LAN BY: 0EXPIRES 1/0$/05O
�OHR: �'� TEL. 0: '—f �MGNADESER�4VICE
LIU, HUATANG (626) 309=50A,- 1 " lAt
5817 41'DA AV l f
rE`1P 017$01824 iAPPLICANT: -__�___...� TEL. O:_
j ' jjT 1C-o r.?dPS
9515 E. CAMINO REAL (626) 215NG 2211- I
i_ _
ARC,�D?A, CA 9:007 1 iSPECIAL CU WD—IT IQNSa
+i
M.7%
LiU, HUATANG 1626) r.PFFCGiACIS L,.";!E NSFt--:10R -,GNi:TURE
5817 MYDA ST. LlC. NO ! — —
TEMPLE CITY CA 9:-.M N I �7E?•iFFOUAR T�(:IdEr e�:,?c
N_.:C:}' S:�u'1 �fG �Yli yj(1i r'.�:: •__.._. ____._..-._._.Y;L�,....__ , ' _-_�•1
ORIENTAL
10.
9515 E, CAMINO REAL_
ARC�D7A CA 99'.07
j imAININ W.a� kE
(PLASTIC Y/N ME IL
I_ _ iREPORT•ID: DPR265 ROUTE TO: SS050Q 1 !�
I i