HomeMy Public PortalAbout5803 PRIMROSE AVE_Electrical__ RKERS'COMPENSATION DECLARATION I 76A663 10/81 APPLICATION FOR ELECTRICAL PERMITI-hereby ffirm that I have a certificate of consent to self CE-806G
insure, or a certificate of Workers'Compensation Insurance, j COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified copy thereof(Sec. 3800, Lab. C.)
Policy No. Company i FOR APPLICANT TO FILL IN JOB ?
Certified copy is hereby furnished. I New Residential Bldgs. 8 Pools
EACH NO. FEE ADDRESS 0J
❑ Certified copy is fired with the county building inspec- 1 &2-Family, Sq. Ft. $ — $ LOCALITY
tion department. Multi-family Sq. Ft. — NEAREST
Residential Swimming Pools CROSS ST /
Date Applicant OWNER OR
CERTIFICATE OF EXEMPTION FROM WORKERS' FIRM NAME C /s
Outlets: Rec Light Sw._ MAIL
COMPENSATION INSURANCE ADDRESS � � C/�J� ` •�
(This section need not be completed if the work Involved by First 20 t
the permit is for one hundred dollars($100)or loss.) Total No. Additional CITY ��C y� Tel. No.
I certify that in the performance of the work for which this PLAN CHECKAPPLICANT
permit is issued, I shall not employ any person in any manner
so as to become subject to the Worker 'Compensation Laws. Lighting Fixtures First 20 ADDRESS
Total No. Additional
Date pplicant CITY Tel. No.
Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, aftek'makinglolthis Certificate of r
Exemption, you should become subject to the Workers' Range_ Heater_D.W. _ APPLICANT
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 04 Tel. No.2AJ,f-- j
LICENSED CONTRACTORS DECLARATION _
Room Air Cond. LICENSE R
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. REG. NUMBER Z Class.C
(commencing with Section 7000)of Division 3 of the Business ' DISTRICT NOPR D BY
and Professions Code,and my license is in full force and effect. Power Apparatus& Large Appliances �r1 D_
Size&Type HP, KW, KVA, or KVAR 0 V
License Number 4Z111919X2 Lic. Class G—/JP Up to 1 Incl. (�
FINAL
//'' 11 O f� Over 1 to 10 Incl. DATE p
Contractor/-�I f��<f/4�< Date '� 3-v� Over 10 to 50 Incl. VALIDATION
❑ FINAL W
I am exempt under Sec. Over 50 to 100 Inc. BY n
B.&P.C. for this reason Over 100 V)
Date- Services, Swbd., MCC&Panelboards ,_ ► —
0 -200 Amp. Under 600 V
Signature 201 - 1000 Amp. Under 600 V
❑ Over 1000 Amp. or Over 600 V
Exemption for Reg. Maint. Elect.
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
Law for the following reason (Section 7031.5, Business and
Professions Code):
❑ I, as owner of the property, will do the work and the M;sc. Conduits&Conductors
structure is not intended or offered for sale (Section Other(See Complete Fee Schedule)_ ,
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for 0 5 4 a 2 A
the performance of the work for which this permit is issued PERMIT FEE (Sub-Total)
(Sec. 3097, Civ. C.). # 0 0 0 0 0 2
Lender's Name
PLAN CHECKING FEE I o o2-550
0 0 0 5' S 0 U
U
Lender's Address PERMIT ISSUING FEE
I certify that I have read this application and state that the TOTAL FEE 0 9.23-86
above information is correct. I agree to comply with all County
ordinances and State laws regulating Electrical wiring, and
A
rize representatives of this County to enter upon
entioned propertyfor inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
nrtt a Date
COUNTY OF. LOS ANGELES TEMPLE CITY # 0508 ELECTRICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS EL 0508 1109190012
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
LEGAL ID: FEES PAID BIIILDING ADDRESS:
1TR: 6561 IT: 663 1 1 5803 PRIMROSE AV
[FEE DESCRIPTION: QUANTITY: UOM: AMOUNT:1 TEMP CA 917802115
(ASSESSOR INFORMATION NUMBER: I I NEAREST CROSS STREET: WORKMAN
18587-012-001 1A1 PERMIT ISSUANCE FEE 27.80 THOMAS PAGE: 596 GRID: J3 LOCALITY: TEMPLE CITY, Cl
I IG1 OUTLETS-LGT,SW,RECP 1.00 OUT 1..90 1 1
TENANT: IH4 RES RANGE HDS IT 3HP 1.00 HOO 10.90 (ISSUED ON: PROCESSED BY: PLAN BY:
TOTAL FEES 40.60 09/19/11 SR 1
[OWNER: TEL. NO: IFINAL DATE FINAL BY: CODE: I
1WHITLOCK VERA E TRUSTEE (573) 651-1877- I I 1
12145 BELLERIDGE PIKE
CAPE GIRARDAEU MO 1 IDE CRIPTION OF WORK 1
I [ONE OUTLET AND RANGE HOOD
!APPLICANT: TEL. NO'.
DAN & SANDY PROVINES (909) 418-7174-
I ISPECIAL CONDITIONS:
(CONTRACTOR: TEL. NO: [ APPROVALS DATE _ INSPECTOR SIGNATURE
[DANNY AND SANDY PROVINES (909) 418-7174- 1
[ LIC. NO 1 TEMPORARY POWER POLE I [
NONE I I I I
I I [UNDERGROUND CONDUIT 1
(ARCHITECT OR ENGINEER: TEL. NO: [ 1IIFER GROUND [ I
[ LIC. NO: I IROUGH CONDUIT [ I I
IROUGH WIRING 1
I [ [MAIN WATER LINE
I I [PLASTIC Y/N METAL Y/N 1
[ I UTILITY COMPANY NOTIFIED( I I
[ I [ I [ I
IREPORT ID: DPR265 ROUTE TO: BS0508 I [ [
I I I I I I