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Home My Public Portal About5116 PAL MAL AVE_Electrical__ DC7 ' WORKER'S'COMPENSATJON^cCLARATION 7BA669 qPw c,?-91, APPLICATION FOR ELECTRICAL PERMIT ILI t 76A663 I'hetaO:affl"rWthat I.have a o6rd bate 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 FILL IN JOB / Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE ADDRESS �l..LOCALITY ❑ Certified copy is filed with the county building inspection 1&2-Family,Sq.Ft. — $ $ de arment.. Multi-family Sq.Ft. NEAREST CROSS IT. lof Date Applicant Residential Swimming Pools ASSESSOR MAP MAP BOOK Iss " PAGE O PARCEL L951 . CERTIFICATE OF EXEMPTION FROM WORKERS' �. 2 OWNER OR �� Outlets:Rec. Light Sw. ,�` 02 FIRM NAMEFMA COMPENSATION INSURANCE I First 20 (� (This section need not be completed If the work.involved by the MAIL permit Is for one hundred dollars($100)or less.). Total No. � Additional ' ADDRESS �� /f V 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 CH CK become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 APPLICANT Total No. Additional ADDRESS Date Applicant 'RESIDENTIAL APPLIANCES NOT OVER 3 HP. NOTICE TO APPLICANT: If, after making this Certificate of CITY Tel.No. 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 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 10 Incl. (commencing with Section 7000)of Division 3 o the Business and CITY Tel.No. Professions Code,and my license is in full force and effect. Over 10 to 50 Incl. Over 50 to 100 Incl. LICENSE Class. REO.NUMBB ER IlL License Number. Lic.Class Over 100 DISTRICT NO. PROCESSED BY V ". p Services„Swbd.,MCC&Parielboards AL Contractor Date 0-399 Amp.Under 600 V❑ DATE O I am exempt under Sec. 400-7000 Amp.Under 600 V 'A tQ� V VALIDATION V Over 1000 Amp,or Over 600 V FINAL W B.&P.C.for this reason,. BRANCH CIRCUIT FEES BY � �O CD Date: 15A,or 20A,120V,Lighting or Recept. Z Signature 1 To 10 Branch Circuits " ' ' AV 11 To 40 Branch Circuits 41 Or More Branch Circuits `� r ❑ Exernptlon'for Reg.Maint.Elect. 15A,20A,20BV To 277V Lightlng Br,Circuits a SINGLE FAMILY Temp.Power Pole&.Appurtenances �.�,� HOME OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch.Circuit 3303 51.60 for the following reason(Section 7031.5, Business and Professions Additional Sign Branch Circuits _. t Code): Tr !Elis ❑ Misc.Conduits&Conductors I,as owner of the property,will.do the work and the structure TOTAL. ;..a:1 .60 is not intended or offered'for sale(Section 7044, Business Other(See Complete Fee Schedule) CHECK, 51060 and Professions Code). CONSTRUCTION LENDING AGENCY '�'H ANGE `00 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) ; .y civ:c.) 001,1�-00131 9i 8/'74 PLAN CHECKING FEE 6809 '1 All S p07 Lender's Name. JJ PERMIT ISSUING FEE o��p Lender's Address ' I certify that I have read this application and under penalty of puriury state EE that the above information is correct. I agree to comply with all County ordinances and State laws regulating Electrical wiring,and hereby authorize ' rep 4atives of this Ounty to enter upon the above-mentioned property I Ins tion p pos SEE REVERSE FOR EXPLANATORY LANGUAGE DATE IGNATU OF PERMITTEE WORKERS'COMPENSATION DECLARATION 20.0019 DPW 3/87O Y . hereby affirm that 1 have a certificate of consent to self CE�' 1A'PPLICATI'ON FOR E IECTRICAL PERMIT ure, or a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS or certified copy thereof(Se03800, Lab. C.) Policy 41o. Company' FOR APPLICANT TO FILL IN JOB �✓ / ❑Certified copy is hereby furnished. New Residential Bldgs. &Pools EACH NO. FEE ADDRESS J ��J A&Ali. 6 ❑ $ _ 'Certified copy is filed with the county building inspec- 1 &2-Family, Sq. Ft. $ LOCALITYI ' tion department. Multi-family Sq. Ft. NEARESTCROSS ST. Date Applicant Residential Swimming Pools I. OWNER OR FIRM.NAME CERTIFICATE OF EXEMPTION.FROM WORKERS' fOutlets: Rec MAIL COMPENSATION INSURANCE Light Sw._ ADDRESS This section need not be completed if the work involved b First 20 ( P Y Total No. CIN Tel. No, the permit Is for one hundred dollars($100)or less.) Additional �' 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'Compens tion Laws. Lighting.Fixtures First 20 ADDRESS Additional Date Applicant Total No. CITY Tel. No. NOTICE TO APPLICANT: If, after making this Certificate .f Fixed Appliances Not Over 1 HP PERMIT Exemption, you should become subject to the Workers' Range— Heater—D.W. _ APPLICATION �ii�{i 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 — .I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. REG.NUMBER _ Class. .(commencing with Section 7000)of Division'3 of the Business IPower Apparatus&Large Appliances DISTRICT NO. PR SED BY >_ and Professions Code,and my license is in full force and effect. + - D Q o- Size&Type HP, KW, KVA, or KVAR O Q License'N'bMber Lic. Class Up to 1 Incl. I U FINAL 1 I' Over 1 to 10 Incl. I DATE— VALIDATION cc Contractor Date �Y Q I Over 10 to 50 Incl. FINAL ❑ I am exempt under Sec. 4 Over 50 to 100 Inc. gY U 9 B.&P.C. for this reason Over 100 Wd Date:' ( Services,Swbd., MCC&Panelboards , Z 0 200 Amp. Under 600'V ' Signature 201 - 1000 Amp. Under 600 V j ❑ Exemption for Reg. Maint.'EI'ect. �) Over 1000 Amp. or Over 600 V ( I SINGLE FAMILY I' y e c— FEE HOME OWNER-BUILDER DECLARATION Temp. Power Pole&Appurtenances i �'` ®R I hereby affirm that I am exempt from the Contractor's License Sign with One Branch Circuit Law for the following reason (Section 7031.5, Business and I Additional Sign Branch Circuits Professtons.Code): �. I i ]1;�1]I;l 1 4 5 1197 1 I, as owner of the property, will do the work and the Misc. Conduits&Conductors r`,;;X.L� 4 structure is.not intended or offered for sale(Section 7044, Other(See Complete Fee Schedule)_ Business and Professions Code). CONSTRUCTION LENDING.AGENCY ACC r I hereby affirm that there is a construction lending agency for I 330 3 j,i l'I the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) (Sec. 3097, Civ:C.). i T•�EMS i PLAN CHECKING FEE Lender's,Name DO,j fiL 3 00 ' PERMIT ISSUING T i— •f ��s Lender's Address FEE 3�.Q[;t1 I certify that I have read this application.and state that the TOTAL FEE t.{-tl: / above information is correct. I agree to comply with all County CHANGE ,i lj ordinances and State laws regulating Electrical wiring, and hereby authorize representatives of this County to enter upon above-mentio d property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE �I iJ I.rl1 6f 5f ry_ O �tiI�J.�9 1 Ate r ��i®S Signature of Permittee Date - COUNtY OF LOS ANGELES TEMPLE CITY # 0508 ELECTRICAL PERMIT DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS EL 0508 1105240012 BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 PHONE: (626) 285-0488 EXT: LEGAL ID. FEES PAID BUILDING ADDRESS: JTR: 12205 LT: 265116 PAL MAL AV ] (FEE DESCRIPTION: QUANTITY: UOM: AMOUNT:( TEMP CA 917803433 ASSESSOR INFORMATION NUMBER: I I NEAREST CROSS STREET: ARROWOOD 8585-030-031 jAl PERMIT ISSUANCE FEE 27.80 THOMAS PAGE: 597 GRID: C4 LOCALITY: TEMPLE CITY, Cl TENANT. IG1 OUTLETS-LGT,SW,RECP 12.00 OUT 23.30 JG2 LIGHTING FIXTURES 2.00 LGT 3.90 JISSUED ON: PROCESSED BY: PLAN BY: TOTAL FEES 55.00 05/24/11 SR OWNER: TEL. NO: ] (FINAL DATE FINAL BY: CODE: ISANDOVAL RACHEL (626) 443-8098- 15116 PAL MAL AV TEMP 917803433 IMSMIPTION OF WORK ] (FINALIZED EXPIRED PERMIT FOR TUDY ROOM, DEN AND PORCH APPLICANT: TEL. NO: SAME AS OWNER I I I ISPECIAL CONDITIONS: CONTRACTOR: TEL. NO: ] (APPROVALS DATE INSPECTOR SIGNATURE ] SAME AS OWNER ILIC. NO ] ]TEMPORARY POWER POLE ]UNDERGROUND CONDUIT ] ] ]ARCHITECT OR ENGINEER: TSL. N0: JUFER GROUND LIC. NO: ] ]ROUGH CONDUIT ] ROUGH WIRING I (MAIN WATER LINE PLASTIC YIN METAL YIN UTILITY COMPANY NOTIFIED I ] ]REPORT ID: DPR265 ROUTE TO: BS0508