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Home My Public Portal About5005 PAL MAL AVE_Electrical__ i ` WORKERS'COMPENSATION DECLARATION CE-806 10/e1 APPLICATION FOR ELECTRICAL PERMIT I hereby affirm that I have a certificate of consent to self CE-8066 insure!or a 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 ADDRESS d0�� Certified copy is hereby furnished. New Residential Bldgs. 8 Pools EACH NO. FEE I ❑ Certified copy is filed with the county building inspec- 1 &2-Family, Sq. Ft. $ — $ LOCALITY I tion department. Multi-family Sq. Ff. — NEAREST 1 Residential Swimming Pools CROSS ST. Dote Applicant OWNER OR FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw._ MAIL COMPENSATION INSURANCE First 20 ADDRESS (This section need not be completed if the work involved by Total No. Additional CITY Tel. No. the permit Is for one hundred dollars($100)or less.) I PIAN CHECK Of Of 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 Total No. Additional CITY Tel. No. Date pplicant Fixed Appliances Not Over 1 HP PERMIT NOTICE PLICANT: If, of making this Certif' a of APPLICANT Exempti n, you should bec a subject to theWorkers' Range_ Heater—D.W. — 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. — CITY el. No. deemed revoked. Hood _ Fan —Other_ LICENSED CONTRACTORS DECLARATION LICENS OR I hereby affirm that I am licensed under provisions of Chapter 9 Disp. _ Room Air Cond. REG. NUMBERY Class. 6—f (commencing with Section 7000)of Division 3 of the Business DISTRICT NO PRO S BY and Professions Code,and my license is in full force and effect. Power Apparatus 8 Large Appliances _ Size 8 Type HP, KW, KVA, or KVAR Jc Q 0License Number Lic. Class Jo Up to 1 Incl. FINAL 10: Over 1 to 10 Incl. DAT VALI ATION 0 Cant racto , ' ate Over 10 to 50 Incl. W I ❑ FIN l m exem der Sec. Over 50 to 100 Inc. BY in, B.&P.C. for this reason Over 100 Date: Services, Swbd., MCC&Panelboards �) ► ,� Y5311' 0 -200 Amp. Under 600 V v Signature 201 - 1000 Amp. Under 600 V ❑ Exemption for Reg. Maint. Elect. Over 1000 Amp. or Over 600 V 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 Additional Sign Branch Circuits `3 9 9 6 A Law for the following reason (Section 7031.5, Business and # 0 0 0 0 0 Professions Code): ❑ I, as owner of the property, will do the work and the Misc. Conduits&Conductors ( 2550 structure is not intended or offered for sale (Section Other(See Complete Fee Schedule)_ 7044, Business and Professions Code). Poo o 0 o 2 5 5 0 5 U CONSTRUCTION LENDING AGENCY 0 206-86 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 Lender's Address C r 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 and State laws regulating Electrical wiring, and hereby authorize representatives of this County to enter upon he above-mentioned pro erty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE r � C Signature of Permit a Dat COUNTY Of LOS ANGELES TEMPLE CITY # 0508 ECTRICAL PERMIT-) DEPARTMENT OF PUBLIC WORKS 9071 LAS TUNAS Evio508-W11040033 BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 PHONE: (818) 285-0488 EXT: LEGAL ID: FEES PAID BUILDING ADDRESS: TR: 12205 LT: 16 5005 PAL MAL AV FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917803432 ASSESSOR INFORMATION UMBER: NEAREST CROSS STREET: LOWER AZUSA 8585-022-017 Al PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 597 GRID: C4 LOCALITY: TEMPLE CITY G1 OUTLETS-LGT,SW,RECP 1.00 OUT 1.95 TENANT: HA FAU LESS 3HP 1.00 FAU 10.80 ISSUED ON: PROCESSED B LA EXPIRES ON: JB AC UNITS +3-10HP 1.00 AC 19.80 11/04/98 UT 11/04/99 TOTAL FEES 60.30 OWNER: TEL. NO: FINAL DATE FINAL BY: CODE: HSU HUI-MIN (626) 350-5099- `� 5005 PAL MAL AV TEMP 917803432 DESCRIPTIO OF OR EETRICAL FOR NEW HVAC SYS, M APPLICANT: TEL. 0: SAME AS OWNER - SPECIAL CONDITIONS: 13'Elll ES co CONTRACTOR: TEL. N0: APPROVALS DATE INSPECTOR SIGNATURE SAME AS OWNER - d LIC. NO TEMPORARY POWER POLE UNDERGROUND CONDUIT ARCHITECT OR ENGINEER: TEL. NO: UFER GROUND LIC. NO: r/ 1`11111ROUGH CONDUIT ROUGH IRI G �[PULI�� WOUllKS PLASTICTER Y/NLINE METAL Y/N F00__) _ UTILITY COMPANY NOTIFIED U 0 r ❑ 4, Li service Tbs REPORT ID: DPR265 ROUTE TO: BS05O8