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Home My Public Portal About9420 OLIVE ST_Electrical__ WORKERS'COMPENSATIONDECLARATION CAPPLICATION FOR E i CE-806G (2-80) ECTRICAL PERMIT E$06 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,or E a certified copy thereof(Sec.3800,Lab.C.) FOR APPLICANT TO FILL IN JOB Policy No. Company EACH NO. FEE I ADORE V New Residential Bldgs.&Pools Certified copy-is hereby furnished. 1 &2-Family,Sq. Ft. $ '" $ LOCALITY G� ❑ Multi-family Sq. Ft. NEAREST fit, Certified copy is'filed with the county building inspection CROSS ST L.•�- vC.�•- department. Residential Swimming Pools OWNER OR FIRM NAME Date Applicant ' Outlets: Rec. _Light. Sw. MAIL First 20 ADDRESS"c�1'-"`� CERTIFICATE.OF EXEMPTION FROM WORKERS' Total No. Additional CITY Tel No. M7-ZE6 COMPENSATION INSURANCE a PLAN CHECK APPLICANT (This section need not be completed if the work involved U by the permit is for one hundreddollars..($1.00) or less.) Lighting Fixtures First 20 ADDRESS Total No. Additional O I certify that in the performance of the work for which this CITY Tel No. permit is issued, I shall not employ any person in any manner Fixed Appliances Not Over. HP �, PERMIT so as to become subje rkers Co pens Laws. Range_Heater D.W._ !APPLICANT 7/�J Oven _ Dryer_W.M._ ADDRESS..Z9= �. �J, N Date GA-•.:-- Pplicant Top _FAU _(N:H.._ rZ& Hood — Fan _Other_ ,CITY Tel No. JJ NOTICE TO APPLICANT: If, after making this Certificate of Disp. _Room Air Cond.— LICENS .OR Exemption, you should. become subject to the Workers' REG.NUMBER Class G 1� Compensation provisions of the,Labor Code, you must forth- Power Apparatus&Large Appliances DISTRICT NO. PROCES Y with comply with such•provisions or this permit shall be deemed revoked. Size&Type HP,KW,KVA,or KVAR Q Up to 1 Incl. Over 1 to 10 Incl. FINAL LICENSED CONTRACTORDECLARATION DATE S' "► � Over 10 to 50 Incl. � '�� —�r VALIDATION z I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. FINAL 9 (commencing with Section 7000)of Division 3 of the Busi- i Over 100 BY ness and Professions.Code.;and my license is in full force and 4 effect. !Services " ��'�� G•r I� , 0-200 Amp.Under 600 V License Number Lic.Class �+em- 1 201-1000 Amp:Under 600 V .T 1� "�• Contractor sDate L �? `-" / { Over 1000 Amp.or Over 600 V L k I f ; l ' HOME OWNER-BUILDER DECLARATION Temp.Power Pole&Appurtenances � .9' � I hereby affirm that I am exempt from the Contractor's Sign with One Branch Circuit;Additional Sign Branch Circuits License Law for the following reason (Section 7031.5, Busi- ness and Professions.Code): /1 2�,9 A Misc.Conduits&Conductors E] I', as owner of the property, will do the work and the Other(See Complete Fee Schedule)— ! f! structure is not intended or offered for sale (Sectiod o o. 0 0 0 7044,Business and Professions Code). y CONSTRUCTION LENDING AGENCY 2o o 1,9,5.0 I hereby affirm that there is. a construction lending agency _ for the performance of the work for which this pgrmit is pE.RMIT FEE (Sub-Total) 0 0 0 9:4,() . issued(Sec.3097,Civ.C.). I j Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee) 0227-8 1 Lender's Address i -71 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 aiid State laws regulating'.Electrical wiring, and 1 hereby authorize representatives of this County to enter upon ` the a o - finned pr pe pec6ion purposes. SEE'REVERSE FO.k EXPLANATORY LANGUAGE Signature of Permitte Dat + i , • WORKER'S COMPENSATION DECLARATION 20.0019 DPW(12.91) APPLICATION FOR ELECTRICAL PERMIT I�Tereby aiffirm that I have a certificate of consent to self insure, 76A863 or a certificate 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.) P❑OIICy NO. Company FOR APPLICANT TO FILL IN JOB ADDRESS Certified co Is hereby furnished. NO. EACH FEE Py y New Residential Bldgs.&Pools _ $ $ LOCALITY ❑ Certified co Is filed with the count buildinginspection 1&2-Family,Sq.Ft. department. y P Multi-family Sq.Ft. CROSS ST. 7.0 C;L4 i&'b/ Date Applicant Residential Swimming Pools ASMASESSOR ,�i>� `.�i , P BOOK r PAGEW_ I PARCEL V CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: W. OWNER OR COMPENSATION INSURANCE FIRM NAME ,f.0 � � First 20 MAIL (This section need not be completod If the work Involved by the Total No. 4 _ Additional ADDRESS j•�liy permit is for one hundred dollars(0100)or less.) I certify that in the performance of the work for which this permit CITY Tel.No. is issued, I shall not employ any person In any manner so as to PLAN CHECK -�� become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 APPLICANT 0,44, /fp1;1,g5 aster l. L,70 / Total N Additional ADDRESS -� �.T - Date ,7 e Z Applicant � / '�?Y� RESIDENTIAL APPLIANCES NOT OVER 3 HP. �� NOTI T APPLICANT: If, after making this Certificate of CITY 1 j (,6LC�Lt�f6'AfJ� Tel.No. q01-- ZC7 Exemption,you should become subject to the Workers'Compensation OTHER APPLIANCES NOT OVER 3 HP. provisions of the Labor Code, you must forthwith comply with such APPLICANT provisions or this permit shall be deemed revoked. Power Apparatus&Large Appliances '.<-pJ-er LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS I hereby affirm that I am licensed under provisions of Chapter 9 Over 3 to 10 Incl. (commencing with Section 7000)of Division 3 of the Business and CITY Tel.No. Professions Code,and my license Is in full force and effect. Over 10 to 50 Incl. LICENSE OR �, -r-• >' Over 50 t0 100 Incl. REG.NUMBER —�X`x�7 Yj Class. a � j?../� Over 100 DISTRICT NO. PROCESSED BY V License Number J� Llc.Class Services,Swbd.,MCC&Panelboards �Ga' 25e.A-ALL cc Contractor 'r� � Date ff 0-399 Amp.Under 600 V DATE O 400-1000 Amp.Under 600 V F-1 VALIDATION I am exempt under Sec. Over 1000 Amp.or Over 600 V FINAL W a- B.&P.C.for this reason BRANCH CIRCUIT FEES BY CD Z Date: 15A,or 20A,120V,Lighting or Recept. _ Z 1 To 10 Branch Circuits 2 Rx Signature 11 To 40 Branch Circuits ❑ 41 Or More Branch Circuits Exemption for Reg.Maint.Elect. 15A,20A,20 VV To 277V Lighting Br.Circuits SINGLE FAMILY Temp.Power Pole&Appurtenances HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits Code): ❑ I,as owner of the property,will do the work and the structure Misc.Conduits&Conductors is not intended or offered for sale(Section 7044, Business Other(See Complete Fee Schedule) and Professions Code). CONSTRUCTION LENDING AGENCY 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 Lender's Name PERMIT ISSUING FEE Lender's Address TOTAL FEE / I certify that I have read this application and under penalty of purjury 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 Zfor, action p uses. SEE REVERSE FOR EXPLANATORY LANGUAGE �" SIGNATURE OF PERMITTEE 1FDATE ~" COUNTY OF LOS ANGELES TEMPLE CITY # 0508 ELECTRICAL PERMIT DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS EL 0508 0005040050 BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 PHONE: (626) 285-0488 EXT: LEGAL ID: FEES PAID BUILDING ADDRESS: ON FILE 9420 OLIVE ST FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917803156 ASSESSOR INFORMATION BER: NEAREST CROSS STREET: ENCINITA 8590-003-017 Al PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 596 GRID: J4 LOCALITY: TEMPLE CITY HA FAU LESS 3HP 1.00 FAU 10.95 TENANT: JB AC UNITS +3-10HP 1.00 AC 19.65 ISSUED UN: PROCESSED Y: PLAN BY: E PIRES ON: TOTAL FEES 58.35 05/04/00 UT 31/00 OWNER: TEL. NO: FINAL DATE FINAL B CODE: HATLEY FAYE J (626) 287-9307- �" 9420 OLIVE ST S- _40 TEMP 917803156 DESCRIPTION OF WOR ELECTRICAL FOR HVAC SYSTEM APPLICANT: TEL. 0: CYPRESS HEATING AND AIR COND. - 547 S. LORAINE AVE SPECIAL CONDITIONS: GLENDORA, CA CONTRACTOR: TEL. N0 \` APPROVALS DATE INSPECTOR SIGNATURE CYPRESS HEATING AND AIR CONDITIONIN (626) 963-9810- 547 LORAINE AVE LIC. NO TEMPORARY POWER POLE GLENDORA, CA. 91741 593268 C20 UNDERGROUND CONDUIT ARCHITECT OR ENGINEER: T L. N0: I OF R GROUND LIC. NO:� i i ` \\`�1 ROUGH CONDUIT ROUGH WIRING MAIN WATER LINE r_, " J PLASTIC Y/N METAL Y/N � �1 } + 1l J'�� I v \�rUTILITY COMPANY NOT I F I D Ll Ll Ll ��'rvice��®� * ADDITIONAL DATA ON FILE REPORT ID: DPR265 ROUTE TO: BS0508