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Home My Public Portal About5745 ROSEMEAD BLVD_Electrical__ WORKER'S COMPENSATION DECLARATION 20.0019 DPW(12.97) APPLICATION FOR ELECTRICAL PERMIT ll I hereby affirm that I have a certificate of consent to self Insure, 46A6B3 or a ce[tificate,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.) C/ POIICy NO ✓�cany LyQ� FOR APPLICANT TO FILL IN JOB .1 o ADDRESS V LM' Certified copy is hereby furnished. New Residential Bldgs.&Pools NO.1 EACH FEE LOCALITY ❑ 1 &2-Family,Sq.Ft. — $ $ Certified copy is filed with the county building inspection _ NEAREST If department. Multi-family Sq.Ft. CROSS ST. L Date Applicant Residential Swimming Pools ASSESSOR MAP BOOK PAGE PARCEL CERTIFICATE OF EXEMPTIO ROM WORKERS' Outlets:Ree._Light Sw. FIRM OWN NAME (A COMPENSATION INSURANCE First 20 (This section need not be completed If the work Involved by the ADDRESS 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, 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 Total 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 provisions or this permit shall be deemed revoked. Power Apparatus&Large Appliances APPLICANTS.�� S LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRES 10 aA 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 Professions Code,and my license is in full force and effect. Over 10 to 50 Incl, >_ Over 50 to 100 Incl. LICENSE OR Class REG.NUMBER J 7 O ��/��1 Over 100 DISTRICT NO. R SSED BY License Number (J� J Lic.Class p V Services,Swbd.,MCC&Panelboards Q FINAL 0 Contractor Data 0-399 Amp.Under 600 V DATE ❑ 400-1000 Amp.Under 600 V �' '�. VALIDATION V I am exempt under Sec. W Over 1000 Amp.or Over 600 V FINAL p B.&P.C.for this reasonBY fA BRANCH CIRCUIT FEES Date: 15A,or 20A,120V,Lighting or Recept. 44"1 — 1 To 10 Branch Circuits Signature 11 To 40 Branch Circuits ❑ 41 Or More Branch Circuits - Exemption for Reg.Maim.Elect. 15A,20A,208V To 277V Lighting Br.Circuits SINGLE FAMILY Temp.Power Pole&Appurtenances w HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit ,.__ : a 77 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 Code): v :•: C-F=1 ❑ I,as owner of the property,will do the work and the structure Misc.Conduits&Conductors z t•-MI - is not intended or offered for sale(Section 7044, Business Other(See Complete Fee Schedule) i_:i;=L " ;- =aU and Professions Code). CONSTRUCTION LENDING AGENCY t 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 -:r=-tr;„_ri^, ,• t•-• qc* Lender's Name PERMIT ISSUING FEE g `;y _ ANI f e 11 Lender's Address I certify that I have read this application and under penalty of purjury state TOTAL FEE (p 7 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 4rIns ectio purpose . SEE REVERSE FOR EXPLANATORY LANGUAGE I 10 TU E OF PERMITTEE AT WORKER'S COMPENSATION DECLARATION 2D-0019'DPW 9189 I hereby affirm that I have a certificate of consent to self Insure, 78A663 APPLICATION FOR ELECTRICAL PERMIT or a certlflcatb 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.)' 11 l policy No. NWU83756 Compan Vco Insurance SV S d FOR APPLICANT TO FILL IN JOB ADDRES8 ❑ Certified co is hereby furnished. EACH NO. FEE PY New Residential Bldgs.&Pools $ _ $ LOCALITY r7 1 &2-Family,Sq.R. L1A Certified copy is filed with the county building Inspection NEAREST department. Multi-family Sq.Ft. CROSS ST. Data —Applicant 3-92 Applicam . Ssioris W=. Resldential Swimming Pools ASSESSOR MAP BOOK PAGE PARCEL CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Ree._Light Sw. FFIIRM NAME COMPENSATION INSURANCE First 20 (This section need not be completed if the work Involved by the MAIL sS D ' permit is for one hundred dollars($100)or less.) Tel. No. Additional ADORES. 1 certify that in the.performance of the work for which this permit Cl 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.: Llghtlrig Fixtures First 20 APPLICANT �C Total No... Additional ADDRES S Q Date Applicant 15 OR 20A,120V BRANCH CIRCUITS NOTICE TO APPLICANT: If, after making this Certificate of CITY ` Tel.No. Exemption,you should become subject to.the Workers`Compensation 1 TO 10 INCLUSIVE EACH provisions of the Labor Code,you must forthwith comply with such 11 TO-40 INCLUSIVE EACH PERUMCANT provisions or this permit shall be deemed revoked. 41 OR MORE BRANCH CIRCUITS EACH APP LICENSED CONTRACTORS DECLARATION ADDRESS a I hereby affirm that I am licensed under.provisions of Chapter 9 15 OR 20A,208V TO 277V LIGHTING EACH (commencing With.Section 7000)of Division'3 of the Business and CITY ; Tel.No. / (Cr. Professions Code,and my license is in full force and effect. RESIDENTIAL APPLIANCES UP TO 3HP LICENSE ORf/ Power Apparatus&Large Appliances REG.NUMBER CI QC License Number 530 949 LID..clage C-45 Size&Type HP,KW,KVA,or KVAR DISTRICT NO. PR S BY F. I C. 'Up to Incl. v (J M 1' contractor .JUressionS Adyt:%te 7-13-92 Over 3 to 10 Incl. DATE va, ❑ Over 10.to 50'Incl: VALIDATION I am exempt under Sec. Over 50.to 100 Incl. AL B.&P:C.for this reason Over 100 BYAL Services,Swbd.,.MCC&Panelboards Date: Qi-200 Amp.Under 600 V Signature 201,1-1000 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 DECLARATIONI`,,: r I hereby affirm that I am exempt from the Contractor's License Law Sign wi,h One Branch Circuit for the following reason.(Section 7031.5,.Business and Professions Additional-Sign Branch Circuits e�i,` '3 Code): 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) F•_; _' f E55 and Professions Code). -- ' �;,,,_,•.� L,-) CONSTRUCTION LENDING AGENCY r:•••• -• r. 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) 9- Civ;C.) 1. PLAN CHECKING FEE Lender's Name !I tirI •` T. • PERMIT ISSUING FEE Lender's Address Q I certify that I have read this application and state that the above TOTAL FEE 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 / �Ir,�IAWRI�OFE SEE REVERSE FOR EXPLANATORY LANGUAGE DATE ' TION 2D-0019 I her9by affirm otthatt I haveCOMPENSATION a certificate lof consent t tto self insure, 76A663 DPW 9/89 APPLICATION FOR ELECTRICAL PERMIT 76A663 I 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.) I . POIICy.No. Company I FOR APPLICANT TO FILL INJOB �i ADDRESS NO. Certified copy is hereby furnished. New Residential Bldgs. EACH FEE&Pools $ _ $ LOCALITY ❑ Certified copy is filed with the county building inspection 1&2-Family,Sq.Ft. _ NEAREST department. Multi-family Sq.Ff. CROSS Sr. Date Applicant Residential Swimming Pools ASSESSOR a MAP BOOK I PAGE. PARCEL CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec. Imo—Light SW- FIR .NAME COMPENSATION INSURANCE First 20 (This section need not be completed If the work involved by the ' vZ19 ADDRESS permit Is for one hundred dollars($100)or less.) Total Nm Additional 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 t '•� .0 PLAN CFI CK become subject.to the Workers'Compensation Jaws. Lightin..g Fixtures First 20 APPLICANTIf Total No. Additional ADDRESS Date plicant 15 OR 2DA,120V BRANCH CIRCUITS NOTICE TO APPLICANT: If, after Ing t Certifi ate f CITY Tel.No. Exemption,you should become subject o the Workers'Compensation 1 TO 10 INCLUSIVE EACH provisions of the Labor Code,you must forthwith comply with such 11 TO 40 INCLUSIVE EACH PERMIT APPLICANT provisions or this permit shall be.-deemed revoked. 41 OR MORE BRANCH CIRCUITS EACH. LICENSED CONTRACTORS DECLARATIONADDRESS, C I hereby affirmM'that I-am licensed under provisions of Chapter 9 15 OR 20A,208V TO 2LIGHTING EACH 013(commencing with Section 7000)of Division 3 of the Business and. _ CITY a Tel:No. C Professions Code,and my license is in full force and effect. RESIDENTIAL APPLIANCES UP TO 3HP LICENSE R' �/ Power Apparatus&Large Appliances REG.NUMBER CI 00 C (License Number Lic.Classv Size&Type HP,KW,.KVA,.or KVAR DISTRICT NO: PRO ED BY I- iC Up to 31nci. I 0�/ C G 1 Contracto445eJ, Over 3 to,10 Incl. FINAL ate. Z! DATE •.�` f7. 'El Over 10 to 50 Incl. I am exempt under Sec. Over 50 to 100 Incl. VALIDATION FINAL B.&P.C.for this reason Over 100 BY Services,Swbd.,MCC&Panelboards 114 Date: 0-200 Amp.Under 800 V I 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 I hereby affirm that lam exempt from the Contractor's License Law Sign with One Branch Circuit ��;,r L. � „ .-I for the following reason(Section 7031.5, Business and Professions Addlttonal Sign'Brahch Circuits ❑ I,as owner of tfie property,will do the work and the structure Misc.Conduits&Conductors TrjT „�i,�.2'a 'r'_i 'is not intended or offered for sale(Section 7044, Business Other(See Complete Fee Schedule) iW , -- and Professions Code). CONSTRUCTION LENDING AGENCY �• i^`f'kf r= I-'+ 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) ` 3 _ CIV.C.) l PLAN CHECKING FEE O �` _ S - �i”:V92. Lender's Name PERMIT ISSUING FEE 'r='21 J. ,y-L�' Lender's Address. I certify that I have read this.application and state that the above TOTAL;FEE 33 a, ZR Information is correct. I agree to comply with all County ordinances and State law regulating Electrical w Ing nd hereby authorize representati of this County to u the above-mentioned propert Inspect a o s. SEE REVERSE FOR EXPLANATORY LANGUAGE 517 uRr:OF APPLICART OR AGENT - DATE ' I - i COUNTY OF LOS ANGELES TEMPLE CITY # 0508 ELECTRICAL. PERNkIT DEPARTMENT OF PUBLIC WORKS 9071 LAS TUNAS CEL 0508 9817170009 BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 PHONE: (818) 285-0488 EXT: LEGAL ID: FEES PAID ,BUJ.LD G ADDRESS: ON FILE 745 ROS BL FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 91'780 ASSESSOR INFORMATION NUMBER: ' 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 38.85 TENANT: TOTAL FEES 66.60 ISSUED ON: PROCESSED-BY: PLA Y: EXPIRES ON: NU PAIR 11/17/98 UT 11/17/99 OWNER: TEL. NO: FINAL DATE FINAL BY: CALAC INVESTMENT - `Z 5- 4 8 4 SAN DIEGO, CA9211137 DESCRIPTION OF WOR ELECTRICAL FOR NEW SIGN APPLICANT: TEL. NO: SUCCESS SIGN (626) 280-8932- 820 E. VALLEY BLVD. SPECIAL CONDITIONS: SAN GABRIEL, CA CONTRACTOR: TEL. NO: /®`�o� �'0017N�ELES `®��iA\ APPROVALS DATE INSPECTOR SIGNATURE SUCCESS SIGN (626) 280-8932- 820 E VALLEY BLVD LIC. NO �� TEMPORARYPOWER POLE SAN GABRIEL CA 91776 739177 C45 r ` r UNDERGROUND CONDUIT ARCHITECTOR ENGINEER: TE O: �/ `� R GROUND LIC. NO: I I l, i ROUGH CONDUIT ROUGH NG [1 r I� I \1 11 r rr'i)f Lf+' C� 11 MAIN WATER LINE f �'/!f�,�I i, �l `Il' 1 IJ L L �fl PLASTIC Y/N METAL Y/N \ - _ UTILITY COMPANY 0 F D ;�Cw lf-J c �erlrice REPORT ID: DPR265 ROUTE TO: BS0508