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HomeMy Public PortalAbout5703 PRIMROSE AVE_Electrical__ WORKERS'COMPENSATIONDECLARATI.ON �CE806G (2.80) APPLICATION FOR ELECTRICAL PERMIT I hereby affirm that I hive a'certif eilte of consent to self COUNTY OF LOS ANGELES I )J I'NG AND SAFETY insure,or certificate of Workers'Compensation Insurance,or •� a certified copy thereof(Sec.3800,Lab.C.) FOR APPLICANT TO FILL IN JOB Policy No. Company EACH NO.: FEE. . ADDRESS New Residential Bldgs.&Pools 13' Certified copy is hereby furnished. 1 &2-Family.Sq. Ft. $ ' — $ LOCALITY Multi-family Sq. Ft. NEAREST Certified copy is filed with the:county building inspection CROSS ST department. Residential Swimming Pools OWNER OR FIRM NAME 'Dale Applicant Outlets: Rec.—Light Sw. MAIL P First 20 ADDRESS CERTIFICATE OF EXEMPTION FROM'WORKERS' Total No. Additional CIT Tel COMPENSATION INSURANCE PLAN- CHE CK G6 ( 'his section need not be completed if the work involved APPLICANT U by the permit is for one hundred dollars ($100) or-less.) Lighting Fixtures First 20 ,ADDRESS Additional cr. No. 0 I certify.that in the performance of the work for which thisCITY Tel No. � permit is issued I shall not em erson in any manner Fixed Appliances Not Over 1 HP P employ any P PERMIT ,: 0LU so,as to become subject to the Workers'Compensa ion Laws. Range_Heater_D.W._ APPLICAN p, Oven _ Dryer_W.M._ ADDREss Date Applicant k4&7 Top _ FAU _W.H. �� ��� Hood — Fan —Other CITYrrb Tel No. NOTICE TO APPLICANT: If, after making this Certificate of Disp. _Room Air Cond— LICENSE OR Exemption, you should .become subject to the Workers' REG.NUMBE t✓ Cless Compensation provisions of the Labor Code, you must forth- Power Apparatus&Large Appliances DISTRICT NO. PRO BY with comply with ,such provisions or this permit shall be Size&Type HP,KW,KVA,or KVAR ©j deemed revoked. Up to 1 Incl. 6 Aver rover 1 to 10.Incl. DATE LICENSED CONTRACTORS DECLARATIONOver 10 to.50 Incl: VALIDATIO. I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. FINAL BY 9 (commencing,with Section. 7000)of Division 3 of the Busi- Over 100 ness and Professions.Code, and my license Is in full force and effect. Services !-J.0 License N bet Lic.Class C.1— 0-200 Amp. nd�0'Y A0 �i r' 201-1000 Amp.Unde`600 V Contra�� ' Date 'J Over 1000 Amp.or Over 600 V g 1478 HOME OWNER-BUILDER.DECLARATION Temp.Power Pole&Appurtenances' I hereby affirm that I am exempt from the Contractor's :Sign with One Branch Circuit t o o.0 0 o 2 License 'Law for.the following reason (Section 7031.5, Busi- Additional Sign Branch Circuits 2 o o 2�5 0 ness and Professions Code): Misc.Cohduits&.Conductors .ro 0 0241,506- Ell, 241,50U❑ I, as owner of the property, will do the work and the Other(See Complete Fee Schedule)— structure, is not intended or offered for sale (Section I .0,07-81 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is PERMIT FEE (Sub-Total) issued(Sec.3097,Civ.C.). Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee) Lender's Address PERMIT ISSUING FEE 740 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 I• the abo -men 'oned proper y for pection purposes. SEE'REVERSE FOR EXPLANATORY LANGUAGE `Signature of Permittee Date ` COUNTY OF LOb ANGELES I TEMPLE CITY 0508 ELECTRICAL PE Pn1T DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS EL 0508 0410060001 BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 PHONE: (626) 285-0422 EXT: LE : f ES PAI T- — B U ILDIN -AMR SS: TR: 6561 LT: 657 BL: .001 5703 PRIMROSE AV FEF DCS(:PTPTION: (31(ANTIIY: U0r.1: AMOUNT-, TEMP CA 917802508 ASSASS°�INFOR IIO NUMB—EP- NEAREST CROSS STREET: LIVE OAK 8541"'-017-002 Al PERMIT ISSUANCE FEE 27.75 1 THOMAS PAGE: 596 GRID: J3 LOCALITY: TEMPLE CITY, C G1 OUTLETS-LGT,SW,RECP 4.00 OUT 7.80 i TEST.— G2 LIGHTING FIXTURES 2.00 LIST 3.90TS—SUED 0N: PROCESSED—BY: PLAN BY: EXPIRES N: LN OTHCR PNL 0-399 AMPS 1.00 PAN 38.85 10/06/04 JK 04/04/05 TOTAL FEES 78.3"u ONNER: TEL. N0: F1NA:. DATE FINA! 3Y: CODE: _—� YANKOWSKY EDWARD;LORI A (626) 287-1203- , 5707 1MROSE AV TEMP S77802508 DESCRIPTION OF WORK ELECTRICAL UPGRADE GARAGE APPLICANT: TEL. N0: � IsPE(:i4L CONDITIONS: — -- --N CONT(lr7410k': — lEl. NU: �k11'R— [:VA1S i!ATt INSPECTOR SIISkSiUtz"---� SAME A3 OlwNER - LIC. NO ��tiri�h,t�'POOR POLE --1 1 ;,4rTtIND CONDUIT ,�L i VRUff TOR EIN I JEER': -:L. NO. ' �i+�_o r. riUTp- L= -� I �— --- —- --- — iMATN +t'F fi•!t LINE - — - - na,lG I'/N META! YIN II !I Y i- I 1 REPORT 1D: DPR265 ROUTE TO: BS0508