HomeMy Public PortalAbout5440 PERSIMMON AVE_Electrical__ �i VVIaKER'S COMPENSATION DECLARATION 76MA6 9 DPW(12.91) {�
herelfj�'sffirm that I have a certificate of consentito self insure, APPLICATION FOR ELECTRICAL PERMIT lJ
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.) it
policy No. Company FOR APPLICANT TO FILL IN JOB
ADDRESS
NO. EACH FEE LOCALITY
Certified copy is hereby furnished. New Residential Bldgs.&Poois _ $ $
❑ 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 BOOKPAGE PARCEL
OWNER OR ` °
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec._Light Sw. FIRM NAME'
COMPENSATION INSURANCE
Silylid
(This section need not be completed if the work Involved by the First 20 MAIL, r
permit.is for one hundred dollars($700)or'less.) Total No. Additional ADDRESS f
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
ITota..l 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 (j
P P y Power Apparatus&Large Appliances APPLICANT
p..rovisions or this p'erinit shall be deemed revoked'.
LICENSED CONTRACTORS DECLARATION Size&Type P KWW KV o�,KVAR p ADDRESS
I heredy affirm that I am licensed under provisions of Chapter 9 / 417t, Incl. /a
(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 }
Class.
Over 50 to 100 Incl.' REG:NUMBER a
i Over 100 DISTRICT NO. P SED BY V
License Number Lic.Class
..Be anelb rdsDO C - �t.•G�
I FINAL
Contractor Date Amp. oder 0 V DATE
❑ I am exempt under Sec. 400-1006 Amp.Under 600 V Z
Over 1000 Am VALIDATION
P•or Over 600 V W
1 FINAL:
B.&P.C.for this reason BRANCH CIRCUIT FEES BY 0-
CO)
Date: 15A,or 20A,.120V,Lighting or Recept. Z_
1.To 10 Branch Circuits
Signature 11 To 40,Branch Circuits
❑ 41 Or More Branch Circuits w
Exemption for Reg.Maint.Elect. 15A,MA,208V To 2M Lighting Br.Circuits
! SINGLE FAMILY Temp.Power Pole&Appurtenances �'� t°
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit Vii,j1 v t=+�-L)
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 1 ^--
Code): i 3 E :=
as owner of the property,will do the work and the structure Misc.Conduits&Conductors :s t�F.1 X63
is not intended or offered for sale(Section 7044, Business Other(See Complete Fee Schedule) vAH + + -10
and Professions Code). 1_�;
CONSTRUCTION LENDING AGENCY � E.' ell
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) ;'�_. it rp:
Civ.C.). ,�I,t,11'LiJ 1 �.2 1 ;i
PLAN CHECKING FEE F. e—
Lender's Name IA ? 9
PERMIT ISSUING FEE (p
Lender's Address
I certify that.I have read this application and under penalty of purjury state TOTAL FEE
that the above information is correct. I agree to comply with all County
ordinances and State laws regulating Electrical wiring,and hereby authorize
repress
ativea of this County to enter upon the above-mentioned property
for in esti purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
6Am
GNATURE F RMITTEE T '
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 ELECTRICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS EL 0508 0201250018
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
LEGAL ID: FErS PAID BUILDING
TR: 13613 LT: 15 1 5440 PERSIMMONSAV
FEE DESCRIPTION: QUANTIlYY: UOM: AMOUNT: TEMP CA 917802803
ASSESSOR IN0 ' NEAREST CROSS STREET: DAINES
8573-005-003 IA1 PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 597 GRID: C3 LOCALITY: TEMPLE CITY
IG1 OUTLETS-LGT,SW,RECP 5.00 OUT 9,75
TENANT: i TOTAL FEES 37.50 ISSUED ON: PROCESSED BY: PLAN EXPIRES 0 :
01/2-5/02 JK 07/24/02
OWNER: TEL. NO: INAL DATEFI L BY: CODE:
SHIRAI KASUMI -
5440 PERSIMMON AV
TEMP 917802803SCI T 0 0F0RK
14GFCI AND ONE OUTLET
APPLICANT: TE-r.-90-.
ALLEN LIN (626) 284-3260-
2618 W MAIN ST #C SPECIAL CONDITIONS:
ALHAMBRA
CONTRACTOR: TEL, 0: APPROVALS DATE INSPECTOR SIGNATURE
AMPB GENERAL CONSTRUCTION (626) 284-3260-
2618 W MAIN ST #C LIC. NO TEMPFjRARY POWER POLE
ALHAMBRA, CA 91801 549061B
UNDERGROUND CONDUIT
ARCHITECT OR ENGINEER: TEL. NO: UFERiGROUND
LIC. NO: ROUGH CONDUIT
ROUGH IR
AIN WATER LINE
PLAS'.IC Y/N METAL Y/N
UTILITY COMPANY OT IED
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REPORT ID: DPR265 ROUTE TO: BS0508
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