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HomeMy Public PortalAbout5725 ROSEMEAD BLVD_Electrical__ WORKER'S COMPENSATION DECLARATION 20-09 683 DPW(12-91) APPLICATION FOR ELECTRICAL PERMIT LJ I hereby affirm that I have a certificate of consent to self insure, or a certificVe 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.) Policy NO. Company FOR APPLICANT TO FILL IN JOB Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE ❑ — Certified copy is filed with the county building inspection 1 &2-Family,Sq.Ft. $ $ LOCALITY de artment/fir Multi-family Sq.Ft. CROSS ST. Date • Applicant Q� Residential Swimming Pools ASSESSOR 0.1 MAP BOOK I PAGE PARCE CERTIFICCOMPENSAT ONATE OF I INSURANCE 70 .0 FROM WORKERS' SURA CEORKERS' Outlets:Rec. Light Sw. �� O OWNER OR FIRM NAME Zf,(This section need not be completed If the work Involved by the ,, First 20 MAIL l Additiona /, permit is for one hundred dollars(3100)or less.) Total No. ---ADDRESS A40 d7 _.��� 1 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 644 If become subject to the Workers'ComZaV4� Lighting Fixtures / First 20 APPLICANT ` Q d� �� Total No. Additional ADDRESS - Data _ Applicant RESIDENTIAL APPLIANCES NOT OVER 3 HP. NOTICE TO APPLICANT: If, aft r king this Certificate of CITY Tel.No. 3 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 / /Y _7 provisions or this permit shall be deemed revoked. Power Apparatus&Large Appliances APPLICANT ( L 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. `a } LICE.NUMB 35�0 7 Class. �i Over 50 to 100 Incl. REG.NUMBER. t"l! / a License Number �• Lic.Class Over 100 DISTRICT NO. PRO D BY O Services,Swbd., Zurfr s,� a D I & Contractor Date 0-34N., yy�P' p;JFINAL DATE 0 ❑ I am exempt under Sec. 400-1000 Am6 Z. 'Zi VALIDATION V Over 1000 Amp.or Over 800 V FINAL 11 l B.&P.C.for this reasonBRANCH CIRCUIT FEES BY 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 s Exemption for Reg.Maint.Elect. 15A,20A,208V To 277V Lighting Br.Circuits SINGLE FAMILY Temp.Power Pole&Appurtenances �+ HOME OWNER-BUILDER DECLARATION ACC 1r AL I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit �� 188.78for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits Code): 1 ITEM ❑ I,as owner of the property,will do the work and the structure Misc.Conduits&Conductors � ht ITEM G is not intended or offered for sale(Section 7044, Business Other(See Complete Fee Schedule) AL 188.78 t h7 and Professions Code). CHECK 188.7.0 CONSTRUCTION LENDING AGENCY CHANGE o00 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) /� A Civ.C.) PLAN CHECKING FEE F0000-0001 11!23/92 Lender's Name 6542 1 ' Aid 9-013 PERMIT ISSUING FEE 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 UUU ordinances a dState laws regulating Electrical wiring,and hereby authorize repress t es of this County enter upon the above-mentioned property for on perp o J SEE REVERSE FOR EXPLANATORY LANGUAGE rdrAn A UR OF PERMITTE DATE WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12.91) APPLICATION FOR ELECTRICAL PERMIT u 76A663 I hereby affirm that I have a certificate of consent to self insure, 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.) Policy No. Company FOR APPLICANT TO FILL IN JOB ADDRESS��� Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE$ $1&2-Family,Sq.Ft. LOCALITY _ Certified copy is filed with the county building Inspection NEAREST department. Multi-family Sq.Ft. cRosS ST. Date Applicant Residential Swimming Pools ASSESSOR MAP BOOK PAGE I.PARCEL CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec._Light Sw. OWNER OR COMPENSATION INSURANCE FIRM NAME First 20 pThis section need not be completed If the work Involved MAIL ermit is for one hundred dollars($700)or less.) Total No. Additional ADDRESS 1 certify that In the performance of for which ermit CITY is issued, I shall not employ person in any ma so as t PLAN CH iecome subj t to the Wor Compensati La Lighting Fixtures First 20 APPLICANT / 'L Total No. Additional ADDRE Date Applic RESIDENTIAL APPLIANCES NOT OVER 3 HP. NOT E T AP CANT: If, r aking this of CITY Tel.No. E ptio ,you sho Id become subject to the Workers'Compensa OTHER APPLIANCES NOT OVER 3 HP. IT ovis' s of the Labor Code,you must forthwith comply with such APPLICANT prov' ons or this permit shall be deemed revoked. Power Apparatus&Large Appliances LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS Z r 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.Nq� Professions Code,and my license is in full force and effect. Over 10 to 50 Incl. Over 50 t0 100 Incl. LICENSE OR Class. REG.NUMBER O /'L' Over 100 DISTRICT NO. PR C BY V L se Number r c. C� ff Services,Swbd.,MCC&Panelboards �/ r 0-399 Amp.Under 600 V Contracto " e L 400 1000 Amp.Under 600 V DATE ter)/��t U ❑ am exempt under Sec. 77 Over 1000 Amp.or Over 800 V FINAL ` VALIDATION d B.&P.C.for.this reason BRANCH CIRCUIT FEES BY COZ Date: 15A,or 20X,120V,Lighting or Recept. 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 Ughting Br.Circuits 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 Law gv C M=a for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits ;n 1 a Code): :`-I r_ u-3.F4 Zr ❑ I,as owner of the property,will do the work and the structure Misc.Conduits&Conductors 1 ITEM IS is not intended or offered for sale(Section 7044, Business Other(See Complete Fee Schedule) pool. - --� ICS and Professions Code). I)-f(��- �`' °O -- • CONSTRUCTION LENDING AGENCY r I hereby affirm that there is a construction lending agency for the CHANGE n{( performance of the work for which this permit is issued(Sec. 3097, PERMIT FEE (Sub-Total) Civ.C.) PLAN CHECKING FEE r^, Lender's Name 001011-1100,! r f 1=!7'-r PERMIT ISSUING FEE 2 - 603 i AN 11:13 Lender's Address I certify thq.UuweT this application and anal f p fury state TOTAL FEE 3 j ;ha?t ova infor tion is correct. to com all County nces and Stat aws regulacal wkin nd reby authorize epresentatives of is ant pon th ova- entione ropert for inspection p pose ,� /a+p SEE REVERSE FOR EXPLANATORY LANGUAGE RE OF PERMITTEE DATE L �r •' WORKER'S COMPENSATION DECLARATION83 DPW(12.91) APPLICATION FOR ELECTRICAL PERMIT LI I hereby affirm that I have a certifjdate'bf consent to self Insure, , or a certWcate of Worker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS BUILDING AND SAFETY DIV. copy thereof. /�(Seeccc...3800 Lib. C:) Policy No// �COmpan I D FOR APPLICANT TO FILL IN JOB ADDRESS Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE LOCALITY $ $Ft S -Family, q. . — Certified copy is filed with the county building Inspection 1&2 _ NEAREST ®• department. Multi-family Sq.Ft. CROSS ST. G 4 d•� s Date Applicant Residential Swimming Pools ASSESSOR MAP BOOK PAGE PARCEL CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER OF! COMPENSATION INSURANCE Outlets:Rec._Light Sw. ?� FIRM NAME 9 c.� (This.,section need not be completed if the work Involved by the MAIL Total No. +�d First 20 Additional ADDRESS permit is for one hundred dollars($100)or less.) �. I certify hot in the performance of the worfor which this perm it Cissue gitITY Tel.No. k shall not employ any person in any manner so as to PLAN CHECK becom subject to the Workers'Com ation Laws. Lighting Fixtures o First 20 APPLICANT //'% �' �Rt"'�"�- D�� Total No.�. Addlti0nal ADDRESS Dat Applica 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 provisions or this permit shall be deemed revoked. Power Apparatus&Large Appliances " LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS 26d I hereby affirm that I am licensed under provisions of Chapter 9Over 3 to 10 Incl.(commencing with Section 7000)'of Division 3 of the Business and CITE'Professions Code,a my license Is in full force and effect. Over 10 to 50 Incl. LICENSE'OR prClass:Over 50 to 100 Incl. REQ.NUMBER ,/ 0 Over 100 DISTRICT NO. 91� Q License Number �� Lic.Class �� +0V e,f� / Services,.Swbd.,MCC&Panelboards y© it t7I �y`[e d ® 5 0-399 Amp.Under 600 V Bd t7 FINAL '� 0 C DATE ❑ I am• - 400-1000 Amp.Under 600 V Z:_- i ACUATLI TION V exempt under Sec. Over 1000 Amp.dr Over 600V FINAL- U A!SL, B.&P.C.for this reason BRANCH CIRCUIT FEES BV X303 r45.V.A) Date:. 15A,or 20A,120V,Lighting or Recept. 2 ITEMS Z 1 To 10 Branch Circuits s ~ Signature 328 . 95' g 11 To 40 Branch Circuits TOTAL��, ❑ Exemption for Reg.Malnf.Elect. 15A,20A,208V To 277v fighting B�Circe°'� ';!s?,m� SINGLE FAMILY Temp.Power Pole&Appurtenances CHANGE CID HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit I hereby.affirm that I a'mexempt from the'Contractor's License Law for the following reason (Section 7031,5, Business and Professions Additional'Sign Branch-Circuits. Code): lI�I:(i UI / i' 1 ❑ I,as owner of the property,will do the work and the structure Misc.Conduits&Conductors is not Intended or offered for sale(Section 7044, Business Other(See Complete Fee Schedule) and Professions Code): CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the G performance of the work for which this permit is issued (Sec. 3097', PERMIT FEE (Sub-Total) / O d Civ.C.) PLAN CHECKING FEE g Lender's Name PERMIT ISSUING FEE Lender's Address I certify that I have rea application and under penalty of purJury state TOTAL FEE that the above inf at1. Is is correct. I agree to com ith all County ordinances and tel s regul I ctric Irl nd reby authorize representati of t • 'County to ant up ove- ioned property for inspec' n p osea. SEE REVERSE FOR EXPLANATORY LANGUAGE SIG RE OF PE E DATE COUNTY OF LOS ANGELES TEMPLE CITY # 0508 ELECTRICAL PERMIT • DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS EL 0508 0301130020 BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 PHONE: (626) 285-0488 EXT: LEGAL ID: FEES PAID-- I D GR • ON FILE 5725 ROSEMEAD BL FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 91780 ASSESSOR ORM 0 NEAREST CROSS STREET: LAS TUNAS 5397-012-043 Al PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: GRID: LOCALITY: TEMPLE CITY K1 SIGNS, OUTLINE LGT 1.00 SIG 6.25 TENANT: TOTAL FEES 34.00 ISSUED ON: PROCESSED 8 PI ON: ROADHOUSE COFFEE 01/17/03 JK 07/16/03 OWNER: TEL. N0: FINIPTE FINAL BY: CODE: CALAC INVESTMENT - 3709 SAN DIEGO, CA9211137 DESCRIPTION OF WOR EXPOSED NEON SIGN "YOUR NEIGHBORHOOD COFFEE SHOP SINCE 94" APPLICANT: EL. NO: SANCHEZ (626) 401-9282- 2216 MERCED AVENUE SPECIAL CONDITIONS: SOUTH EL MONTE - CONTRACTOR: TEL. N0: �cj` y ���1APPROVALS DATE INSPECTOR SIGNATURE A N S SIGNS (562) 801-0033- �, \ 9845 1/2 ALBURTIS AVE LIC. NOTEMPORARY POWER POLE SANTA FE SPRINGS CA 90670 569180 C45 /,� UNDERGROUND CONDUIT ARCHITECT OR ENGINEER: O: �4 '`� \1V+ ER GROUND LIC. NO / 1,� ROUGH CONDUIT ROUGH R r,� MAIN WATER LI `� NE PLASTIC Y/N METAL Y/N—-- --- ------ / U I COMPANY NOTIFIED ervic REPORT ID: DPR265 ROUTE TO: BS0508