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HomeMy Public PortalAbout5707 ROSEMEAD BLVD_Electrical__ WORKER'S COMPENSATION DECLARATION 200019 DPW(12-e1) APPUC y�TOON FOR E1 ECTRICAL PERMIT ll ,I hereby affirm that I have a certificate of consent to self insure, 78A689 �s6'�i A II{� A l 0..Gv 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.) POIICYNo. 126&3&J Company S Q�l����i(� FOR APPLICANT TO FILL IN ADDRESS ©7 5 Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE $ $ LOCALITY � N� ❑ Certified copy is filed with the county building inspection 1&2-Family,Sq.Ft. _ NEAREST department. Multi.-family Sq.Ft. CROSS ST. Date - b `� Applicant �Gi.� Residential Swimming Pools MAP SSSOK PAGE PARCEL CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec._Light Sw. FlNN E OR COMPENSATION INSURANCE l Tcompleted If the work Involved b First 20 MAIL (' his-section need not be com P y the ADDRESS S' A permit is for one hundred dollars($100)or less.) Total No. Additional I certify that in the performance of the work for which this permit CITY Tel.No. Is Issued;'1 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 _rw&n- S . Total No.' Additional ADDRESS 142 we Date• Applicant RESIDENTIAL APPLIANCES NOT OVER 3 HP. NOTICE TO APPLICANT: If., after making this Certificate of CITY G 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 50 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 of 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. gEGNNUMBER 6 2. Class' d License Number Ll..Classy ^ . Over 100 DISTRICT NO. i7y�gSED BY U Services,Swbd.,MCC&Panelboards Contractor ` Date — 0-399 Amp.Under 600 V DATE 0 F1400-1000 Amp,Under 600 V ,. i V I am exempt under Sec. VALIDATION Ili Over 1000 Amp.or Over 600 V FINAL 0. S.&P.C.for this reason BRANCH CIRCUIT FEES BY fn 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 Exemption for Reg.Maint.Elect. 15A,20A,208V To 277V Lighting Br.Circuits 2 SINGLE FAMILY Temp.Power Pole&Appurtenances IL HOME OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit v - for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits 11 ! y `-,Cr �•: Code): ❑ I,as owner of the property,will do the.work and the structure Misc.Conduits&Conductors I 't is not intended or offered for sale(Section 7044, Business Other(See Complete Fee Schedule) P11 roix and Professions Code). CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the `=1i=j UL performance of the work for which this permit is issued (Sec.. 3097, PERMIT FEE (Sub-Total) Civ.C.) PLAN CHECKING FEE. Lender's Name PERMIT ISSUING FEE 3 AM 9"M Lender's Address p I certify that I have read this application and under penalty of purjury state TOTAL FEE ® O that the 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 the above-mentioned property for inspection urposes. SEE REVERSE FOR EXPLANATORY LANGUAGE n � r - Ig-• %- SIGNATURE OF PERMITTEE DATE WORKER'S COMPENSATION DECLARATION 776ASBa DPW(1E-91) APPLICATION FOR ELECTRICAL PERMIT L1 I hereby�affirsn-•that I have a certificate of consent to self insure, or a certificate of Worker's Compensation Insurance, or d certified COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS BUILDING AND SAFETY DIV. tippyth reof(Sec.3800 Lab:C.) Policy No. E_BCoompaR FOR APPLICANT TO FILL IN JOB �f-/�� ❑, ADDRESS �y Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE LOCALITY LJ Certified co is filed with the coun uil ' 1 &2-Family,Sq.Ft. — $ $ department. 9 inspection Multi-family Sq.Ft. NEAREST ROSS ST. i--date / Applicant Residential Swimming Pools ASSESSOR MAP BOOK PAGE PARCEL CERTIFICATE OF EXEMPTION.FRO.M WORKERS' Outlets:Rec. Light Sw. //i� FIRM NAME COMPENSATION INSURANCE D i // / First 20 (This section need not be completed If the work involved by the MAIL Total No. Additional/ ADORES permit Is for one hundred dollars($100)or less.) I certify that in the.performance of the work for which this permit CrV_�4je Tel.No. is issued, I shall not employ any person in any manner so as to t PIAN CHECK become subject to the Workers'Compensation Laws., Lighting Fixtures First 20 ✓ APPLICANT Total No. Additional •7� 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 Power Apparatus&Large A n s C3` APPLICANT provisions or this permit shall be deemed revoked. ������- QS /�:J LICENSED CONTRACTORS DECLARATION Size&.Type HP,KW, r AR ADDRESS I hereby affirm that I'am licensed under,provisions of Chapter 9AA �g0011 214 Al. (commencing'with Section 7000) of'Division 3 of the Business and Over 3to 101nc1. Cir Tel.No* Over 10 to 50 Incl. ,-,-� , Professions Code,and my license is in full force and effect. LICENSE OR p ,%j Over 50 to 100 Incl. REG.NUMBEROp 0� Clasa.Z >' A- n•+ r, a G� Over 100 DISTRICT NO. P O SSE 9Y' O License Number , lLIC.Class Services,Swb C� anelbo rds �,Qa ia .sn E Contract Date 0-`�•m5p. nder0 V FINAL DATE O ❑ p 400-1000 Amp.Under 600 V 5+ ,gyp Y"dLID TION I am xem t un r Sec.. Over 1000 Amp.or Over 600 V FINAL III B.&P.C.for this reason BRANCH CIRCUIT FEES By MSP -=1 `' �a Date: 15A,or 20A,120V,Lighting or Recept. n r;-,t, Z 1 To 10 Branch Circuits RIS Signature f .+ - 11 To 40 Branch.Circuits ;til rst_ 1343.71-1 t, ❑ 41 Or More Branch Circuits �'11"K t'•+ a „ Exemption for Reg.Maint.Elect. I5A,:20A,208V To 277V Lighting Br.Circuits i HIE.t•IF 1343. y; 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 for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits Code): ❑ I,as owner of the property,will do the work and the structure Misc.Conduits&Conductors P9 yrs is not intended or offered for sale(Section 7044, Business Other(See Complete Fee Schedule) C,I - oft �3`52 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 issued (Sec. 3097, PERMIT FEE (Sub-Total) Civ.C.) PLAN CHECKING FEE ilio. J o Lender's Name / PERMIT ISSUING FEE a!a Lender's Address ®O I certify that I have read this application and under penalty of purjury state TOTAL FEE d that the 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 the above-mentioned property fo ' on puri s SEE REVERSE FOR EXPLANATORY LANGUAGE SIONATUrRE ERMITTEE DATE ' I ' COUNTY OF LOS ANGELES TEMPLE CITY # 0508 ELECTRICAL PERMIT DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS EL 0508 0210290002 BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 PHONE: (626) 285-0488 EXT: ✓� ,� LEGAL ID: FESPAID BUILDM—M-DREqS: ON FILE 5707 ROSEMEAD 01- FEE DESCRIPTION: QUANTITY: LION: AMOUNT: TEMP CA 91780 S 0 U NEAREST CROSS STREET: LAS TUNAS 5397-012-043 Al PERMIT ISSUANCE FEE 27,75 THOMAS PAGE: GRID: LOCALITY: TEMPLE CITY G1 OUTLETS-LGT,SW,RECP 39.00 OUT 64.65 G2 LIGHTING FIXTURES 24.00 LGT 44.40 ISSUED 0 L EXPIRES ON: JB AC UNITS +3-10HP 1.00 AC 19.65 10/29/02 JK 04/27/03 LB 200 AMP PANELS, MCC 2.00 PAN 77.70 OWNER: TEL. NO: TOTAL FEES 234.15 INA D FINA BY: CODE: 3A7LO�C INVESTMENT - SAN DIEGO, CA9211137S 0 ELECT ICAL FOR T.I., REINSTALL 2 200AMP SUBPANELS APPLICANT- MIN SHANGKO (626) 286-4662- 5453 BALDWIN AVE SPECIAL CONDITIONS: TEMPLE CITY CONTRACTOR: TEL. N0: `:�; `s ' 'r� , APPROVALS DATE INSPECTOR SIGNATURE KO ELECTRIC CO. (626) 286-4662- 5453 BALDWIN AVENUE LIC. NO a �.' % R R POLE TEMPLE CITY CA 91780 591509 C10 t•r ;.' \ UNDERGROUND CONDUI CI EC OR ENGINEER: TE ! i \, ^, RGROUND LIC. NO': ROUGH CONDUIT - - -- ROUGH W G ��J� •�� MAIN WATER LINE PLASTIC Y/N METAL Y/N - UTILITY COMPANYNOTIFIED .�'� �(,� �- — _gyp - •�, REPORT ID: DPR265 ROUTE TO: BS0508