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Home My Public Portal About5791 ROSEMEAD BLVD_Electrical__ WORKER'S COMPENSATION DECLARATION 20.0019 DPW(12.91) APPLICATION FOR ELECTRICAL PERMIT I hereby effirpi'that I Have a certificate of consent to self insure, 76A663 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 Nd V "'1/Company Gr`p*-t14, FOR APPLICANT TO FILL IN JOB ADDRESS1rw�PiYn ,v Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE LOCALITY $ $Ft Sq. . _ Certified copy is filed with the county building inspection 1&2-Family, NEAREST department. At Multi-family Sq.Ft. CROSS ST Date Applicant Residential Swimmiag Pools ASSESSOR MAP BOOK PAGE PARCEL CERTIFICATE OF EXEMPTION FROM WO KERS' Outlets:Rec._Light Sw. FIRM NAME COMPENSATION INSURANCE First 20 MAIL (This section need not be completed If the work Involved by the Total No. Additional ADDRESS permit is for one hundred dollars($100)or less.) 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. 9 , s provisions of the Labor Code,you must forthwith comply with such PERMIT P Y P Y APPLICAN GL Gd provisions or this permit shall be deemed revoked. Power Apparatus&Large Appliances 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 T.I.No. Professions Code,and my license is in full force and effect. Over 10 to 50 Incl. LICENSE OR J y Class. } 1 Over 50 to 100 Incl. REG.NUMBER x'306O 0- �� Over 100 DISTRICT NO. P O SED BY U License Number ((V!!!!! D Lic.Class Services,Swbd.,MCC&Panelboards 4 Contract ��S•Date p�`S1 0-399 Amp.Under 600 V DANE O r_1 I am exempt under ec. 400-1000 Amp.Under 600 V �� `q� W VALIDATION Over 1000 Amp.or Over 600 V FINAL fl B.&P.C.for this reason BRANCH CIRCUIT FEES BY Z Date: 15A,or 20A,120V,Lighting or Recept. — 1 To 10 Branch Circuits Signature 11 To 40 Branch Circuits F141 Or More Branch Circuits Exemption for Reg.Maint.Elect. 15A,20A,208V To 277V Lighting Br.Circuits SINGLE FAMILY Temp.Power Pole&Appurtenances HOME OWNER-BUILDER DECLARATION 9• Sign with One Branch Circuit 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): d � ❑ I,as owner of the property,will do the work and the structure Misc.Conduits&Conductors v 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 performance of the work for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total) Civ.C.) ` tta PLAN CHECKING FEE. Lender's Name 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 ordinances and State laws regulating Electrical wiring,and hereby authorize representatives of this County to enter upon the above-mentioned property for�ion purposes. �- SEE REVERSE FOR EXPLANATORY LANGUAGE sI �l J I7f SIGNATURE OF MITI DATE WORKER'S h ve a certificate DECLARATION 76A669 DPW 91e9 APPLICATION FOR ELECTRICAL PERMIT 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( ec.3800 Lab.C.) Policy No. b 2-Company �- l' FOR APPLICANT TO FILL IN JOB ❑ ADDRESS Certified copy is hereby furnished. New Residential Bldgs.&Pools EACH NO. FEE LOCALITY 1 &2-Family,Sq.Ft. $ _ $ Certified copy is filed with the c my b 'kspection NEAREST department. Multi-family Sq.Ft. CROSS ST. A Residential Swimming Pools ASSESSOR Date pplicantMAP BOOK PAGE PARCEL CERTIFICATE OF EXEMPTION FROM Outlets:Rec. Light Sw. OR WR NAME COMPENSATION INSNE OR URAN First io MAIL (This section need not be completed if the work involved by the Total No. Additional ADDRESS permit is for one hundred dollars($100)or les I certify that in the performance of the work f r hich this permit CITY Tel.Nd� 2 is issued, I shall not employ any person in a manner so as to PLAN CHEL l y become subject to the Workers' Com ensation L s. Lighting Fixtures First 20 APPLICANT Date Total No. Additional ADDRESS 1 Cf / Appf, 1 NOTICE TO APPL ANT: If, a er maki this Certi cate of 15 OR 20A,120V BRANCH CIRCUITS CITY 7e1.No. Exemption,you should become subject to the orkers'Co ensation 1 TO 10 INCLUSIVE EACH IT provisions of the Labor Code, you must for with comply with such 11 TO 40 INCLUSIVE EACH APPLICANT provisions or this permit shall be deemed revoked. 41 OR MORE BRANCH CIRCUITS EACH LICENSED CONTRACTORS DECLARATION ADDRESS > I hereby affirm that I am licensed under provisions of Chapter 9 15 OR 20A,208V TO 277V LIGHTING EACH Q (commencing with Section 7000)of Division 3 of the Business and CITY Tel.No. _3L Professions Code,and my license is in full force and effect. RESIDENTIAL APPLIANCES UP TO 3HP LICENSE OR n C �Q Lic.Class Power Apparatus&Large Appliances REG.NUMBER Class.C<2" Size&Type HP,KW,KVA,or KVAR DISTRICT NO. PROCESSED BY License Number f Up to 3 Incl. (f yc � U. ^� Over 3 to 10 Incl. FINAL a Contractor S Date r DATE U VALIDATION F1clOver 10 to 50 Incl. t I am exempt under Sec. Over 50 to 100 In . AL B.&P.C.for this reason Over 100 6vAL Services,Swbd.,MCC&Panelboards Date: 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 Law 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 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 performance of the work for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total) �1 Civ.C.) PLAN CHECKING FEE Lender's Name PERMIT ISSUING FEE j Lender's Address I certify that I have read this application and state that the above TOTAL FEE 1. information is correct. I agree to comply with all County ordinances and State laws regulating Electrical wiring, and hereby authorize represen lives o this County to enter upon the above-mentioned property r insp tion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE SIGNATU OF APPLI NT ORAGENJ DATE i WORKERS'COMPENSATION DECLARATION CE Bo6G 1081 APPLICATION FOR ELECTRICAL PERMIT I hereby affilm that I*A.ave,a•certificate of consent to self insure, y or'a certificate of Workers' Compensation Insurance, or a certified (( COUNTY OF LOS ANGELES BUILDING AND SAFETY copy Ahereoofff(�(Seec.338809,Lab.C:) Policy NCompany , FOR APPLICANT TO FILL IN JOB 0 Certified copy is hereby furnished. 30 �� New Residential Bldgs.&Pools EACH NO. FEE ADDRESS 1 &2-Family,Sq.Ft. - $ $ LOCALITY + Certified copy is filed with the county buildin action — NEAREST department. �� ,Multi-family Sq.Ft; .. CROSS 3T. Date �� Applicant Residential Swimming Pools OWNER OR O FIRM NAME CERTIFICATE OF EXEMPTION FROM WORK S' d MAIL COMPENSATION INSURANCE Outlets:Re �Lfgh 'I. Sw.— ;•�{j ADDRESS (This section need not be completed if the work involved by the ppA� First 20 , permit is:for one hundred dollars($100)or,less.) Total No._(Z✓ ,Additional CITY Tel.No. I certify that in the performance of the work for which this permit PLAN LICANT K is issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS Total No. ate/ Additional / -CITY Tel.No. Date Applicant Fixed Appliances Not Over 1 HP + NOTICE TO .APPLICANT: If; after• making this. Certificate of PERMIT Exemption,you should become subject.to the Workers.'Compensation L lt�PLICANT Range_ Heater D.W. provisions of the Labor Code,you must forthwith comply,with such Oben Dryer_W.M._ ADDRESS � � - provisions or this permit shall be deemed revoked. Top FAU W.H. LICENSED CONTRACTORS DECLARATION Hood DispFan Other._ CITY ' Tel.N . /_ 76 _ .., I hereby affirm that I am licensed under provisions of:Chapter 9 LICENSE OR 7 (commencing with'Section 7000)of Division 3 of the Business and . — Room Air'Gond. Class. 'REG.NUMBERy ��+ Professions Code,:and"my I)eehse Is in full force and effect. DISTRICT NO. P SSED BY Power Apparatus&Large Appliances ' :Size&Type HP,KVV;IcVA,or KVAR �e" p License Number 77 Lic.Class _ + Up to 1 Incl. FINAL �� fN� f J Over 1 to 10 Ind. DATE `f.f, VALIDATION p Contracto("'y�_MM--1 bate i r�� Over 10 to 50 Incl, AM ❑ I am exempt under Sec. Over 50 to 100 Inc. FBY INAL &P.C.for this reason over 100 iT I.+ 0 B , Services,.Swbd.,MCC&Panelboards' ® C Date: 0_200 Amp.Under 600 V CHANGE GE Signature 201 1000 Amp.Under 600 V 'Exemption for Reg:.Maint.Elect. Oxer 1000 Amp.or Over 600 V 00000001 7/.14195 SINGLE FAMILY Temp.Power Pole&Appurtenances �•- 1 AM' °4�' HOME OWNER-BUILDER DECLARATION i Sign with One Branch Circuit 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 Brach Circuits 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) , and.Professions Code). i CONSTRUCTION LENDING AGENCY , hereby affirm that there is a construction lending agency for the Performance of the work for which this permit is issued(Sec.3097, I. PERMIT FEE (Sub Total) -Civ.C.). I PLAN CHECKING FEE ✓ �T, �p�l �d ' Lender's Name • PERMIT ISSUING FEE Lender's Address 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 + ' property for inspection purpo SEE REVERSE FOR EXPLANATORY LANGUAGE _7, 9-Ir-4ignaftfire of Permittee Date { 2D-001 ,trm thdtR'have a certificate DECLARATION 7BA689 DPW 9/89 APPLICATION FOR ELECTRICAL PERMIT 76A663 I hereby affirm th6t 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 I&�E .4 0 Company A r Al n � FOR APPLICANT TO FILL IN Joe J17-0�•7 ADDRESS / S rr L Certified copy Is hereby furnished. New Residential Bldgs.&Pools EACH NO. FEE ❑ $ _ $ LOCALITY M G� Ll ` P.� Certified copy is filed with the county building inspection 1 &2-Family,Sq.Ft. department. Multi-family Sq.Ft. — CROSS Sr. Date g // ; ; Applicant Residential Swimming Pools ASSESSOR _ MAP BOOK I PAGE PARCEL CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER OR COMPENSATION INSURANCE Outlets:Rec. )6 Light_ Sw. s • 7o � FIRM NAME (This section need not be completed if the work Involved by the �,, First 20 MAIL permit is for one hundred dollars($100)or less.) Total No. Additional -Alt- ADDRESS 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 t0 PLAN CHECK become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 APPLICANT Total No.M4 Additional ADDRESS 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 PERMIT provisions or this permit shall be deemed revoked. 41 OR MORE BRANCH CIRCUITS EACH LICENSED CONTRACTORS DECLARATION ADDRESS! 0 pp -� (f d I hereby affirm that I am licensed under provisions of Chapter 9 15 OR 20A,208V TO 277V LIGHTING EACH Q (commencing with Section 7000) of Division 3 of the Business and CITY •C` M aay 6 Tel. o.S109454,93 V Professions Code,and my license Is in full force and effect. RESIDENTIAL APPLIANCES UP TO 3HP LICENSE OR ✓✓r✓illl_� Power Apparatus&Large Appliances REG.NUMBER I Class.eB jr ff Size&Type HP,KW,KVA,or KVAR DISTRICT NO. POC SED BY Q License Number Lic.Class.S�� Up to 3 Incl. �0o U F' f� / Over 3 to 10 Incl. FINAL Contractor V ��S/ Date Q r — DATE Over 10 to 50 Incl. CA ® ��¢ ❑ 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 Date: 0-200 Amp.Under 600 V Signature 201-1000 Amp.Under 600 V ❑ �' Over 1000 Amp..or Over 600 V Exemption for Reg.Mani.Elect. - SINGLE FAMILY Temp.Power Pole&Appurtenances (j�T u8 HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit I hereby affirm that I am exempt from the Contractor's License Law g ;; S +: for the following reason(Section 7031.5, Business and Professions Additional Sign Branch Circuits " 33CT3.2 Code): s. 1 ITEMS ❑ i I,as owner of the property,will do the work and the structure Misc.Conduits&Conductors .�.I��L 63.27 �e�,� Is not intended or offered for sale(Section 7044, Business Other(See Complete Fee Schedule) and Professions Code). , CHECK 63.27 CONSTRUCTION LENDING AGENCY ;�� 'GE ,10 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 0000-0001 9/14/92 Lender's Name 5�f�J�3` 1 AM 11;�, 6 PERMIT ISSUING FEE Lender's Address TOTAL FEE I certify that I have read this application and state that the above TO •02 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 1 t nn purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE SIGNATURE O APPLICANT OR AGENT DATE COUNTY OF LOS ANGELES TEMPLE CITY # 0508 ELECTRICAL PERMIT DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS EL 0508 0403040032 BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 PHONE: (626) 285-0488 EXT: LEGAL-ID: FEES PAID BUILDING ADDRESS: ON FILE 5791 ROSEMEAD BL N FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 91780 ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET: LAS TUNAS Al PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: GRID: LOCALITY: TEMPLE CITY, C K1 SIGNS, OUTLINE LGT 1.00 SIG 38.85 TENANT: TOTAL FEES 66.60 ISSUED ON: PROCESSED BY: PAN BY: EXPIRES ON: 03/04/04 VG 08/31/04 OWNER: TEL. NO: FIN ATE FIN L BY: CODE: SUSAN LEW & ASSOCIATES (626) 292-6638- 5825 ROSEMEAD BLVD. TEMPLE CITY 91780 DESCRIPTION 0 WOR ELECTRICAL FOR SIGN APPLICANT: TEL. O: DIVERSIFIED SIGNS INC. (714) 701-1330- SPECIAL CONDITIONS: CONTRACTOR: TEL. NO: APPROVALS DATE INSPECTOR SIGNATURE DIVERSIFIED SIGNS AND GRAPHICS (714) 701-1330- 5602 E LA PALMA AVE LIC. NO TEMPORARY-POWER POLE ANAHEIM CA 92807 737055 C45 UNDERGROUND CONDUIT ARCHITECT OR ENGINEER: TEL. NO: UFEP. GROUND LIC. NO: ROUGH CONDUIT ROUGH WIRING MAIN WATER LINE PLASTIC Y/N METAL Y/N UTILITY COMPANY NOTIFIED REPORT ID: DPR265 ROUTE TO: BS0508