HomeMy Public PortalAbout9944 OLIVE ST_Electrical__ WORKER'S COMPENSATION DECLARATION 8 DPW(72.91) APPLICATION FOR ELECTRICAL PERMIT
78A68
I hereby affirm°•that I have a certificate of consent to self Insure, 7BA663
or a%ortificate 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. Company I FOR APPLICANT TO FILL IN pDDRES3' (L �L/ / �� /��/C t
❑ Certified copy is hereby.furnished. New Residential Bldgs.&Pools NO. EACH FEE
❑ — $ $
LOCALITY. �.jPL�' . .0(Tr
Certified copy is filed with the county building inspection 1&2-Family,Sq.Ft.
department, Multi-family Sq.Ft. NEARESTCROSS ST.
Date Applicant Residential Swimming Pools ASSESSOR
MAP BOOK I PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' OWNINAR ME /��Zti
COMPENSATION INSURANCE Outlets:Rec._Light Sw. FIRM ME. Nj� G
r�
(This section need not be completed the work Involved by the First 20 MAIL
Total No. Additional , ADDRESS $r r 0//�S7
permit Is for one hundred dollars($1000)or less.)
I certify that in the performance of the work-for which this permit OIT1� MPLE 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
Total No. Additional
C Z ADDRESS
> Date/mss– Applicant RESIDENTIAL APPLIANCES NOT OVER 3'HP.
NOTICE TO APPLICANT: If, efte aking this ertif• ate of CITY Tel.No.
Exemption,.you should become a b]96JAo the Workers'Compensation OTHER APPLIANCES NOT OVER 3 HP.
provisions of the Labor Code,you Must forthwith comply with such PERMIT.'
.provisions or this permit shall be deemed.revoked. Power Apparatus&Large Appliances APPLICANT
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 70 Incl:
(commencing with Section 7000)of Division 3 of the Business and CITY F Tel.No.
Professions Code,and my license is in full force and effect. Over 10 to 50 Incl. LICENSE OR
• Over 50 to 100 Incl. REG.NUMBER Class. d
License Number Lie.Class
Over 100 DISTRICT NO. PROLE BY O
- - �(
Services,Swbd'.,MCC&Panelboards •V
Contractor 34 to FINAL
Date 0-399 Amp.Under 600 V DATE
❑ 400-7000 Amp.Under 600 Z� VALIDATION V
I am exempt under Sec. Over 1000 Amp,or Over 600 V FINAL W
'B.&P.C.for this reason BRANCH CIRCUIT FEES BY �' 4.
Date: 15A,or.20A,120V,Lighting or Recept. co
Z_
'1'To 10 Branch Circuits
Signature 11 To 40 Branch Circuits
❑ 41 Or More Branch Circuits
Exemption for Reg.Malnt,Elect. 15A,20A,208V To 277V Lighting Br.Circuits
SINGLE FAMILY Temp.Power Pole&AppurtenancesAL
HOMEOWNER-BUILDER DECLARATION A-(CT■V
ith C
B
with One Branch Circuit I hereby affirm that I am.exempt from the Contractor's License Law Sign wa
for the following reason(Section 7031.5, Business and Professions Additional Sign Branch'Circuits 3307 '•'9_-J-J
Code):
1 ITEMS
I,as owner of the property,will do the work and the structure Misc.Conduits&Conductorso
is not intended or offered for sale.(Section 7044,.Business Other(See Complete Fee Schedule) TOTAL _ 5
and Professions Code), is
CK 199.519
CONSTRUCTION LENDING AGENCY1 CHANGE .
n
I hereby affirm that there is a construction:lending agency for the Colic
00
performance of the work for which this permit is issued(Sec. 3097, PERMIT.FEE (Sub-Total)
Civ.C.) '
PLAN CHECKING FEE 0000-0001 12/ 3/92
Lender's Name 6840 1 AMIMIA'
' PERMIT ISSUING FEE 2 'J
Lender's Address
I certify that I have read this application and under penalty,of purjury state TOTAL FEEg,S
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
for inspect• oses. SEE REVERSE FOR EXPLANATORY LANGUAGE
P4C 3 F2
SIGNA F PERMITTEE DATE
WORKERS'COMPENSATION DECLARATION 76-806 10/81 APPLICATION FOR ELECTRICAL PERMIT
I liereby.aff�m that I'have a certificate of consent tb'self insure, CE-806G
or a ce►ttficate'of Workers'Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof(Sec.3600,Lab.C.j
Policy No. Company afQ��
❑ FOR APPLICANT TO FILL IN JOB 0 VAF Sr Wrl4pllp
Certified copy is hereby furnished. j New Residential Bldgs.&Pools EACH NO. FEEADDRESS T
S — $ _
❑ • Certified copy Is filed with the county building inspection 1 &2-Family, q•Ft. $ LOCALITY—
department. Multi-family Sq.Ft. NEAREST
Residential Swimming Pools CROSS ST.
Date Applicant OWNER OR YEAAla N2ait-4
FIRM NAME
CERTIFICATE OF EXEMPTION'FROM WORKERS' r i
Outlets:Rec—Light—SW.— MAIL f (fit �": (f[Rib` 51'COMPENSATION INSURANCE. ADDRESS
(This section need not be completed If the work Involved by the First 20
permit Is for one hundred.dollars($100)or less.) Total No. Additional CITY �//h nfr it ( Tel.No:
1 certify that in the performance of the.work for which this permit PLAN CHECK
-is.issued, I shall not'employ any person in any manner so as to APPLICANT
ecome subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS
tc Total No. Additional CITYTel.No.
Date . � 3 7 Z Applicant Fixed Appliances Not Over 1 HP
NOTICE TO APPLICANT: If, after making this Certm to of PERMIT
ExerAption,you should become subjedt to the Workers'Compensation Range, Heater_ D.W. APPLICANT W//'e
provisions of the Labor Code,you must forthwith comply with such Oven _ Dryer_ W.M._ ADDRESS
provisions or this permit shall be deemed revoked. Top _ FAU W.H. _ • CITY Tel.No.
LICENSED CONTRACTORS DECLARATION Hood _ Fan Other_ 6 j
I hereby.•affirm that I,am licensed under provisions of Chapter 8Y 'C LICENSE.OR
Disp: Room Air Cond. REG.NUMBER Class.
(commencing with,Section 7000)of Division 3 of the Business and
Professions Code,and my license is in full force and.effect. DISTRICT'NO.. PROCESS B
Power Apparatus&Large Appliances +—
Size&Type HP,KW,KVA,or KVAR �` Q
License Number - Lic.Class Up to 1 Incl., FINAL �+
Over 1 to 10 Incl. DATE Z
Contractor Date
Over 10 to 50 Inc]. VALIDATION
V
FINAL
I am exempt under Sec. Over 50 to 100 Inc. BY W
Over 100
8.8P.C.for this reason -
Services,Swbd.,MCC&Panelboards Z- Z_
Date: 0-200 Amp.Under 600 V y� i as
Signature 201 - 1000 Amp.Under 600 V
Over 1000 Amp.or Over 600 V• �`�`='t
❑• Exemption for Reg.Maint.Elect.
T i=i-wfy�:
_ .s
SINGLE FAMILY Temp.Power'Pole&Appurtenances r�._.,1 :-p.4•-,p C
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit' "t AL -"s"y' -
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 r.;F-i(�� •. .�.:,o'i•,'
Code):
Misc.Conduits&Conductors.
LiN I,as owner of the'property,will do the work and the structure
isnot intended or offered for sale (Section 7044, Business. Other,(See Complete Fee Schedule)
" and Professions Code)..' ,
CONSTRUCTION LENDING AGENCY f "( 1'1AM *}'o(F j
-I hereby affirm that there is a construction:lending-agency for'the :r
•performance of the work for which this perndt is issued(Sec.3087, PERMIT FEE' (Sub-Total)
Civ.C.).
PLAN CHECKING FEE
Lender's Name ,
PERMIT ISSUING FEE' Z2
Lender%'Address
I certify that I have. read this application and state that.the above ,TOTAL FEE
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 insp coon purposes. SEE REVERSE FOR.EXPLANATORY.LANGUAGE
Signa uf Permittee Date
WORKERS COMPENSATION DECLARATION 766g0019DPYV3/87 APPLICATION FOR ELECTRICAL PERMIT Q
I.he,,■eby t�ffirm-thM I have"a certificate of consent to self cE-. G
insure, or a Certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
,or crcertified copy thereof(Sec. 3800, Lab. C.)
Policy No. Company FOR APPLICANT TO FILL IN JOB djlti(,fv p. o fVE r 7fiMPLE CNr
Certified copy is hereby furnished. New Residential Bidgs. $Pools EACH NO. FEE ADDRESS
Certified copy is filed with the county building inspec- 1 $2-Family, Sq. Ft.
—isI LOCALITY
Fition department. Multi-family Sq. Ft. — NEAREST
CROSS Date Applicant PP
Residential Swimming Pools OWIJERS0
FIRM NAME YM IG O F1.t kLl.2A W A
CERTIFICATE OF EXEMPTION FROM WORKERS' �Li � MAIL
Outlets: Rec ght Sw._ L 44 4 y �, OL/VE s
COMPENSATION INSURANCE o ADDRESS
First 20
(This section need not be completed If the-work involved by �� CITY 'TE M NLE C f T r Tel. No.
the permit•is'for one hundred dollars($100)or Less.) Total No. Additional
PLAN CHECK
I certify that in the performaince .of the work for which this APPLICANT
permit Is issued, I shall not employ any person in any manner
s�as to become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS
✓/ r I Additional •
Date c 3 7 Z Applicant ' Total No. CITY Tel. No.
NOTICE TO APPLICANT: If, after aking this Certi tate of Fixed Appliances Not Over 1 HP PERMIT
Exemption, you should become subject to the Workers' Range.— Heater—D.W. — APPLICATION
Compensation provisions of the Labor Code, you must forth- Oven — Dryer —W.M.— ADDRESS
with comply with such provisions or this permit shall be Top — FAU —W.H. —
deemed revoked. Hood — Fan —Other— CITY Tel. No.
-LICENSED CONTRACTORS DECLARATION LICENSE OR
Disp. _ Room Air Cond. — Class.
I hereby affirm that I am licensed-under provisions of Chapter'9 REG. NUMBER
(commencing with Section 7000)of Division 3 of the Business Power Apparatus$Large Appliances DISTRICT NO. PRggSSED BY d
and Professions Code,and my license is in full force and effect.
Size$Type HP, KW, KVA, or KVAR U
License Number - • Lic. Class Up to 1 Incl. FINAL
DATE
Over 1 to 10 Incl. Z. 7� VALIDATION O
Contractor Date Over 10 to 50 Incl. U
❑ FINAL
I am exempt under Sec. Over 50 to 100 Inc. BY W
B.$P.C. for this reason Over 1,00 D
Services,Swbd.,MCC$Panelboards
Date: 0-200 Amp. Under 600 V Z
Signature 201.- 1000 Amp. Under 600 V
Exemption for Reg. Nlaint. Elect. Over 1000 Amp. or Over 600 V
SINGLE FAMILY Temp. Power Pole$Appurtenances
HOME OWNER-BUILDER DECLARATION h -
I hereby affirm that I'am exempt from the Contractor's License
Sign witOne Branch Circuit .:
Law for the following reason Section 7031.5, Business and Additional Sign Branch Circuits rv'- a
Professions Code): .,;,-
3
® I, as owner of the property, will do the work and the
Misc. Conduits$Conductors
structure is not intended or offered for sale(Section 7044, Other(See Complete Fee Schedule)— i j � ;:
Business and Professions Code). -�
.CONSTRUCTION LENDING AGENCY '
6. 10
1 hereby affirm,that there is a construction lending agency for t: w't3 ■i1
the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) Q
(Sec. 3097, Civ. C.). ) ;"WiGt °!,l
PLAN CHECKING FEE
Lender's Name PERMIT ISSUING FEE
/3
r r
Lender's Address
1 certify that I have read this application and state that the TOTAL FEE A. f11 81117 All 9:4L
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 abov -mentioned roperty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
SoAoture of Permltte Date ®'
W10RKER'SLOMPENSATIONDECLARATION 720639DPW 9/89 APPLICATION; FOR. ELECTRICAL PERMIT
I hel'eby affjrfh,jhat I have a certificate of consent to self Insure,
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.)
Policy No. Company FOR APPLICANT TO RLL IN ADDRESS
❑ Certified copy is hereby furnished. New Residential Bldgs.&Pools EACH NO. FEE
❑ $ _ $ LOCALITY L F C�T Y
Certified copy is filed with the county building Inspection 1&2 Family,.Sq.Ft.
CIL-
department. Multi-family Sq.Ft. CROSS ST.
Date Applicant Residential Swimming Pools ASSESSOR
! MAP BOOK PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rao.—Light Sw. OWNER OR Y
COMPENSATION INSURANCE g FIRM NAME 1 f/r ICI0 Fia&%t a a
(This section need not be completed if the work Involved by the FirstMAIL S
permit Is for one hundred dollars($700)or less:) Total No. Additional. ADDRESS c(`f OLIVE 7
I certify that in the performance of the work for which this permit CITY '(E'(y pte C I =. Tel.No.
is issued, I shall not employ any person in any manner so as to PLAN CHECK
bec a subject to the Workers'Compensation.Laws. Lighting Fixtures First 20 APPLICANT
Total No. Additional
� ADDRESS
.It,.
3 Z Applicant `"T �✓ "` 15 OR 20A,120V BRANCH CIRCUITS
NOTI E TO APPLICANT: If, after eking this C ificate of CITY Tel.No.
Exemption,you should become subje to the Workers'Compensation 1 TO 10 INCLUSIVE EACH
PERMIT
provisions of the Labor Code,you must forthwith comply with such' 11 T0.40INCLUSIVE EACH APPLICANT P Y PY
provisions or this permit shall be deemed.-revoked. 41 OR MORE BRANCH CIRCUITS EACH• APPLICANT
LICENSED CONTRACTORS DECLARATION ADDRESS.
I hereby affirm that I am licensed under provisions of ChapteF 9 15 OR 20A,208V TO 277V LIGHTING EACH
(commencing with Section 7000)of Division'3 of the Business and CITY Tel.No. U
Professions Code,and my license is in full force and effect. RESIDENTIAL APPLIANCES UP TO 3HP LICENSE OR
Power'Apparatus&Large Appliances REG.NUMBER Class.
License Number Lic.Class Size&Type HP,KW,KVA,or KVAR DISTRICT NO. PROCESSED BY H
Up to 3.Incl, �0 J
Over 3 to 10 Incl. FINAL G-
Contractor Date Over 10 to 50 Incl. DATE Z
❑ 1 am exempt under Sec. Over 50 to 100 Incl. 1 Z-�'�'L' VALIDATION
FINAL
B'.&P.C.for this reason
Over 100 BY
Services,Swbd.,MCC&Panelboards _
Date: 0-200 Amp.Under 800 V
Signature 201-1000 Amp.Under 600 V
Over 1000 Amp.or Over 600 V
ElExemption for Reg.Maint.Elect.
SINGLE FAMILY Temp.Power Pole&Appurtenances M _
HOME OWNER-BUILDER DECLARATION „
I hereby affirm that I am exempt.from the Contractor's License Law Sign with One Branch Circuit 4'S
for the following reason(Section 7031.5, Business and Professions Additional Sign.Branch Circuits r';
I'Code): .y��
f!�
y
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) , ",;r 1,';lali ,„„RR aF y;;
and Professions Code). „-
CONSTRUCTION LENDING AGENCY i•
I hereby affirm that there is a construction lending agency for the
performance of the work for which this permit 1.s Issued(Sec.3097, PERMIT FEE (Sub-Total)
Civ.C.) '
PLAN CHECKINGFEE "'
Lender's Name I `ON10)=-I::(�j• :� ;rJ'7
PERMIT ISSUING FEE 7 1
Lender's Address
1 certify that I have read this application and state that the above TOTAL FEE �r
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 f spectlon. up ses. _ s SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATUREJOF APPLICANT OR AGEPT DATE
V OTKER'S CbMPENSATION DECLARATION X01 DPW 9189
63
I hereby affirm that I have a certificate of consent to self,insure, APPLICATION FOR ELECTRICAL PERMIT
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.)
Policy No. Company FOR APPLICANT TO FILL IN pBpRES3 VE
❑ Certified copy is hereby furnished. New Residential Bldgs.&Pools EACH NO. FEE .
❑ $ _ $ LOCALITY
Certified.copy is filed with the county building inspection t&2-Family,Sq.Ft. NEAREST
department.. Multi-family Sq.Ft. CROSS ST.
Date Applicant Residential Swimming Pools ASSESSOR
MAP BOOK PAGE d PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec.2L_Light SW. O 0 OWNER OR
COMPENSATION INSURANCE, , FIRM NAME b1kI0 �(1kfd2A WQ
(This section need not be completed if the work Involved by the First io MAIL p
permit Is for one hundred dollars($100)or less.) Total No. Additional ADDRESS 1�' 0L111,,:' S
I certify that in.the performance of the work for which this permit CITY_rE(-7KE C f TTel.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
/ Total No. Additional
Q ADDRESS
Date `Z Applicant • 15 OR 20A,120V BRANCH CIRCUITS �'
NOTICE TO APPLICANT:.If, amaking this Ce ificate of CITY Tel.No.
fte
Exemption,you should become subje to the Workers'Compensation 1 TO 10 INCLUSIVE EACH 1���'e�
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 �.
LICENSED CONTRACTORS DECLARATION ADDRESS f1
I hereby affirm that I am licensed under provisions of Chapter 9 15 OR 20A,208V TO 277V LIGHTING EACH O
(commencing with Section 7000)of Division 3 of the Business and CITY Tel.No. V
Professions Code,and my license Is In full force.andsffect. RESIDENTIAL APPLIANCES UP TO 3HP UCENSE.ORa:Power Apparatus&Large Appliances REG.NUMBER Class.
License Number Lic.Class Size&Type HP,KW .,KVA,or KVAR DISTRICT.NO. PROCESSED BY O
Up to 3 incl: 8 0 a
Over 3 to 10 Incl. FINAL.,
Contractor Date DATE
Over 10 to 50 Incl. Z
I am exempt under Sec. Over 50 to 100 Incl. 7--FINAL VALIDATION
'
B.&P.C.for this reason Over 100' BY
Services,Swbd.,MCC&Panelboards
Date: 0-200 Amp.Under 600 V
Signature 201-1000 Amp.Under 600 V
El
Over 1000 Amp.or Over 600 V
Exemption for Reg.Maim.Elect. 41.
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. =" ` r•_•``:
Code):
19 I,as owner of the property,will do the work and the structure Misc.Conduits&Conductors ,1,7. - f �•
Is not Intended or offered for sale(Section 7044, Business Other(See Complete Fee Schedule) —� ' `413
and Professions Code). , ,;,+;u r.tr ;�'' •`7
CONSTRUCTION LENDING AGENCY ,r=; r�:� .1,,j
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 '•=i- '�"-�--I-- �"f 7
Lender's Name I G
PERMIT ISSUING FEE. J r' ' '
Lender's Address /
I certify that I have read this,application and state that the above TOTAL FEE CJ
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
propert ins action pu os . SEE REVERSE FOR EXPLANATORY'LANGt1AGE
-22
SIGNATURF APPUCANTO AGENT DATE
WORKERS'COMPENSATION DECLARATION CEAs 53 10/81 APPLICATION FOR ELEbTRICAL PERMIT
I hereby affirm tkat I have a certificate of consent to self Insure, CE-s EG
or a certificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof'(Sec.3800,Lab.C.) 1
Policy No. Company FOR APPLICANT TO FILL IN :JOB oC�V J T 7X'M Q rr
❑ Certified copy is hereby furnished. Nel EACH NO. FEE ;'ADDRESS Residential Bldgs.&Pools LOCALITY T ht ` C
❑ Gertified copy is filed with the county building inspection 1 &2-Family,Sq.Ft $ _ $ I a 1 ��
NEAREST
department. Multi-family Sq.Ft. CROSS Si IIQ.w v i , 4V-e
Residential Swimming Pools (OWNER OR
Date Applicant i
FlRM NAME YvA4 0 FM W 2A 6V A
CERTIFICATE OFCOMPEXE ON INSURANCE WORKERS' Ou lets:Rec—Light_Sw.— , �MAJIL
ADDREss
(This section need not be completed if the work.involved by the First 20
Total No
permit is for one hundred dollars($100)or less.) . Additional (CITY'I E M pt jE CITY Tel.No.S'`P#.1 d
(PLAN CHECK
I certify that in the performance of the work for Which this'permit
IAPPIJCANT
is issued, I shall not employ any person in any manner so as to I
become subject to the Workers'Compensation Laws. Lig Ming Fixtures First 20 (ADDRESS
Additional
Total No. (CITY Tel.No.
Date Applicant Fined Appliances:Not Over 1.HP
NOTICE TO APPLICANT: If, after making. this Certificate of ,PERMIT �/ f,
Exemption,you should become subject to the Workers'Compensation 'Range_ Heater . D.W. _ �PPLICANT ' t" ill O Fu Ui at-I�►�' e1
provisions of the.Labor Code,you must forthwith comply with such Oven — Dryer-_ W.M._ (ADDRESS 114 E
provisions or this permit shall be deemed revoked. Top. — FAU _ W.H. _ T / '
CITY l Fl<•1 t C ( Tel.No. 1- 6G(�
LICENSED CONTRACTORS DECLARATION 'Hood — Fan _ Other_
OR
I hereby affirm that I am licensed under provisions of Chapter 9 iDisp. — Room Air Cond. REG.NEUMBBER Clara
(commencing with Section 7000)of Division 3 of the Business and REG.NUMBER
Professions Code,and my license is in full.force and effect. Pa
r Apparatus&.Large Appliances DISTRICT NO. r O� PR SSED
Up to 1 Incl.
Size&Type HP,KW,KVA,or KVAR tf
�
License Number" Lic.Class FINAL 8
Over 1 to 10 Incl. DATE i VALIDATION
Contractor . Date Over 1.0'to 50 Incl. V
FINAL
❑ I am exempt under Sec. I Over 50 to 100 Inc. BY W
0-
B.&P.C.for this reason i over 100 iN
Se vices,Swbd.,,MCC&P.anelboards VVV
Z
Date: 0-200 Amp.Under 600 V- M nV
Signature 201 - 1000 Amp.Under 600 V
El Exemption
1000 Amp.or Over 600 V
Exemption for Reg.Maint.Elect.
i
SINGLE FAMILY Te, p.Power Pole&Appurtenances 2
HOME OWNER-BUILDER DECLARATION Si with One Branch CircuitT°a
I hereby affirm that I am exempt from the Contractor's License Law Ad itional Sign Branch Circuits
for the following reason(Section 7031.5,Business and Professions 337 1° )
Code):
❑. 1,as owner of the property,will do the work and the structure Mi c.Conduits&Conductors i ITEMS
is not intended or offered for sale (Section 7044, Business Ot er(See Complete Fee Schedule) — Poo- TOTAL 31.00
and Professions Code).
CHECKi°
CONSTRUCTION LENDING AGENCY
I hereby aff.irm.that:there is a construction lending agency for the ? CHANC .00
performance of the work for Which this permit:is issued'(Sec.3097, PEM IT FEE (Sub Total)
Civ.C,).
Lender's Name
PL CHECKING FEE 0000_0001 9,/ 3/90
i p
PE.MIT ISSUING FEE J? 0473 1 AM p'°°41
Lender's Address
I certify that.I have read this application and state that the above TO AL FEE �.�O .J
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 Purp ser. SEE REVERSE FOR EXPLANATORY LANGUAGE
7 114Y 3 f 0
Signa of Permittee Date `
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 ELECTRICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS EL 0508 1009280005
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
LEGAL ID: FEES PAID BUILDING ADDRESS:
ITR: 6755 IT: 10 BL: .001 9944 OLIVE ST
[FEE DESCRIPTION: QUANTITY: UOM: AMOUNT:] TEMP CA 917803238
(ASSESSOR INFORMATION NUMBER: I I NEAREST CROSS STREET: BALDWIN
18589-005-005 IA1 PERMIT ISSUANCE FEE 27.80 I THOMAS PAGE: 597 GRID: A4 LOCALITY: TEMPLE CITY, Cl
I IG1 OUTLETS-LGT,SW,RECP 12.00 OUT 23.30 I
(TENANT: IG2 LIGHTING FIXTURES 3.00 LGT 5.80 (ISSUED ON: PROCESSED BY: PLAN BY:
TOTAL FEES 56.90 09/28/10 SR
(OWNER: TEL. NO: �FINAL DATE FI BY: CODE: I
IFUKUZAWA, VERONIKA - I 1
19944 OLIVE ST 1
ITEMP 917803238 IAM DE RIPTION OF WORK 1
(ELECTRICAL FOR NEW ADDITIO I
[ I [ I
[APPLICANT: TEL. NO: I I
IVICTOR FELIX (323) 215-9783- I 1 I
1 ISPECIAL CONDITIONS: I
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[CONTRACTOR: TEL. NO: I (APPROVALS DATE INSPECTOR SIGNATURE
ICEM CONSTRUCTION INC. (760) 792-6523- I 1
18207 BROOKGREEN RD LIC. NO I ]TEMPORARY POWER POLE ]
DOWNEY, CA 90240 941346 B I I I I [
I [UNDERGROUND CONDUIT I I [
[ARCHITECT OR ENGINEER: TEL. NO: 1UFER GROUND I I I
IMENDOZA, RAMON (323) 724-8333- I 1 1 1 1
12161 S. EASTERN AVE. LIC. NO: I IROUGH CONDUIT I 1 1
(COMMERCE C25255 I I I I
1 ROUGH WIRING
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I IMAIN WATER LINE I 1 1
I ]PLASTIC Y/N METAL Y/N 1 1 1
1 I ]UTILITY COMPANY NOTIFIED( I 1
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1 IREPORT ID: DPR265 ROUTE TO: BS0508 1 ] 1 1
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