HomeMy Public PortalAbout4925 PERSIMMON AVE_Electrical__ WORKER'S COMPENSATION DECLARATION 20.0019 dPW(12.91)
-r 14reby affirm that I have a certificate of consent to self Insure, 76A669 ' APPLICATION FOR ELECTRQ L PERMIT LI
or a certificate of Worker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT.OF PUBLICI.V6RKS BUILDING AND-SAFETY DIV.
copy-,,hereof(Sec.3800 Lab.C.)
M1.w
Policy No. Company FOR APPLICANT TO FILL IN JOB / � `
❑ ADDRESS 7 eA
Certified copy Is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE
$ $ LOCALITY
❑ Certified copy is filed with the county building inspection 1 2-Family,Sq.Ft. _ NEAREST
department. Multi-family Sq.Ft. CROSS ST.
Date Applicant Residential Swimming Pools ASSESSOR
' MAP BOOK PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec._Light Sw. NER OR.
COMPENSATION INSURANCE A L N
First
AIJ
(This section.need not be completed If the.work Involved by the o _MA
permit is for one hundred dollars(6100)or less.) To`al No. Additional
I certify that in the performance of the work for which this permit5g, IC
I
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
Tojal No. Additional ADDRESS
Date Applicant RESIDENTIAL APPLIANCES NOT OVERS 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 suchPERMIT
provisions or this permit shall be deemed revoked. Power'Appa[atus&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 DiOver 10 to 50 Incl.vision 3 of the Business and ; CITY Tel.No.
Professions Cade,.and my•license is in full force and effect. LICENSE OR }
Over 50 to 100 Incl. REG.NUMBER Cless. O
Over 100 DISTRICT NO. P O SED BY
License Number Lic.Class
Seryicbs,Swbd.,MC & aneellb 'd�
FINAL
Contractor Date Ar 600 V DATE 4,3 '
�J U
❑ I am exempt under Sec. 400-1000 Amp.Under 600 V — �)`'G VALIDATION LU
Over 1000 Amp,or Over 600 V FINAL 0.
B.&P.C.for this reasonBRANCH CIRCUIT FEES BY CO.
•
Date:. 15A!or 20A,120V,Lighting or Recept.
" 1 To 10 Branch Circuits ►T �/
Signature 11 To 40 Branch Circuits
❑ 41 Or More Branch Circuits
Exemption for Reg.Maim.Elect. 15A,20A,208V To 277V Lighting Br.Circuits 7
SINGLE FAMILY Temp..Power Pole&Appurtenances g
HOME OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law Sign ate Tith.One Branch Circuit
for the following reason'(Section 7031.5, Business and Professions Additional Sign Branch Circuits ' 37 70.61
Code): 1 I 1 G f,7
91 I,as owner of the property,will do the work and the structure Misc.Conduits&Conductors a--u
is not intended or offered for sale(Section 7044, Business Otherl(See Complete Fee Schedule) TOTAL 910 o 61
and Professions Code). SVoQi
CONSTRUCTION LENDING AGENCY ; - G11�7G
I hereby affirm that there is a construction lending agency for the' '' f�1t1VG .001
performance of the work for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total)
Civ.C.) '
PLAN CHECKING FEE 0000-0001 11/23/92
Lender's.Name
PERMIT ISSUING FEE (y 1 PH121
Lender's Address I A
I certify that I have read this application and under penalty of purjury state TOTAL FEE t'/,
that the above information is correct. I agree to comply with all County ,I
ordinances and State laws regulating Electrical wiring,and hereby authorize
representatives of this County to enter upon the above-mentioned property
for Inspection purposes. I SEE REVERSE FOR EXPLANATORY LANGUAGE
s — '
SIGNA PERMITTEE ' DATE
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 ELECTR L PERMIJT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS EL 0508-990'1060032
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
GA ID: FEES D N PRESS:
TR: 4902 LT: 31 BL: F 4.925- PERSIMM0�,1 AV
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TMP-CA 917804105
ASSESSOR NFORMA ION UMBER: NEAREST CROSS STREET: GRAND
8574-025-026 Al PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 597 GRID: D4 LOCALITY: TEMPLE CITY
G1 OUTLETS-LGT,SW,RECP 16.00 OUT 31.20
TENANT: G2 LIGHTING FIXTURES 4.00 LGT 7 80 ISSUED ON: PROCESSED PAN IRES .
HA FAU LESS 3HP /._Zs89'F!(G /B•�`��q-� 01/06/99 UT 01/06/00 .
JB AC UNITS +3-10HP / /9gp3r}:60
OWNER: TEL. NO: LB 200 AMP PANELS, MCC 2.00 PAN 77.70 FINAL DATE FINAL BYCODE:
LUK•KENT (626) 233-8148- TOTAL FEES 205.65
492§ PERSIMMON AVE. '/'s-`
TEMP 917803148 DESCRIPTION OF W0�
fp�j RICAL FOR NEW AnDITIO
APPLICANT: T 0: /�
SAME AS OWNER
SPECIAL CONDITIONS:
�r�CyEES c
CONTACTOR: TEL. NO: - �oS ��/,.� APPROVALS DATE INSPECTOR SIGNATURE
SAMELIC. NO TEMPORARY POWER POLE
UNDERGROUND CONDUIT
ARCHITECT OR ENGINEER: TEL NO: - ER GROUND
LIC. N< 1111111 ROUGH CONDUIT
I ,
_ ROUGH WIRING
C'U � ��(C ��vl O�K S PLASTICTY/NLIMETAL Y/N
C a T I L I TY C PANY OT D y`�-�-�
L61 ,�S,y�'"" 1nh
❑ `ori
E
46,�c service That�ot
REPORT ID: DPR265 ROUTE TO: BS0508