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Home My Public Portal About5803 ROSEMEAD BLVD_Electrical__ WOIKER'SCOMPENSATIONDECLARATION 200o191)Pwg/eg APPLICATION FOR ELECTRICAL PERMIT I herebyyaffirm At have a certificate of consent to self insure, 76A68 or�a'Cbrtificate''of Worke'r'a Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS BUILDING AND SAFETY DIV. copy thereof(S//e//pp}}gg77{{/pJ0))Lab.C.) /]a/�` app {� Policy No.'s Company�f/7`6 FOR APPLICANT TO-FILL IN ADDRESS ` �� 0�,1 ❑' Certified co is here furnished. EACH 'NO:. FEE 1 PY by New EACH Bldgs.&Pools LOCALITY G 1&2-Family,Sq.Ft.. $ — $ ❑ Certified copy is filed with the county,building inspection _ NEAREST de ment Multi-family Sq.Ft. RT. �/ Residential Swimming Pools 'ASSESSOR Date Applicant ,. MAP BOOK PAGE PARCEL CERTIFICATE.OF EXEMPTION FROM WORKERS' OWNER OR COMPENSATION INSURANCE Outlets:R Light SW. D FIRM;NAME v 1. First 20 (This section-need not be completed If the work Involved by the Total No. Additional AADDDRESS permit is for one hundred dollars($100)or less.) I certify that in the performance of the work for which this permit CITY u Tel:No. Is Issued, I shall not employ any person in.any manner so as to PIAN CHECK become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 APPLICANT Total No. Additional ADDRESS Data Applicant 15 OR 20A,12oV,BRANCH CIRCUITS NOTICE TO APPLICANT: If, after making this Certificate cf 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 �p , provisions or this permit shall be deemed revoked. 4VOR MORE BRANCH CIRCUITS EACH Y V } LICENSED CONTRACTORS DECLARATION ADDRESS I hereb 15 OR 20A,208V TO 277V LIGHTING EACH y.affirm that'I am licensed under provisions of Chapter 9 � (commencing with Section 7000)of Division 3 of the Business and CITY U Prdfesslans Code,and my license is in full force and effect. RESIDENTIAL APPLIANCES UP TO SHP LICENSE OR" p ` Cress. Power Apparatus&Large Appliances REG.NUMBER J�i/ License Number Lic.Class,,� Size&T pe HP,KW,KVA,or KVAR �Q DISTRICT NO. �t p PRC SED BY I... Up to 3 Incl. Over 3 to 10 Incl. FINAL LL Cont ract0 Date DATE Over 10 to 50 Incl. /� _ ❑ I am exempt under Sec. Over 50 to 100 Incl. 4.2 �-/ VALIDATION AL 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.Maint.Elect. SINGLE FAMILY Temp.Power Pole&Appurtenances :�•-- Z. HOME OWNER-BUILDER DECLARATION !"•- ! R With O itne Branch Circuit I hereby affirm that I am,exempt from the Contractor's License Law Sign w �•-h'-7 d"7� �•; for the following reason(Section 7031.5, Business and Professions Additional Sign Branch Circuits C ;.e u, - 'Code)• ��:n+'• ❑ I,as owner of the property;will do the work and the structure Misc.Conduits&Conductors Af ,O, _1!•L";_ - - is not intended or offered for sale(Section 7044, Business Other(See Complete Fee Schedule) !'-! - =� and Professions Code). , .l iR La.S•'i,' S.�W Ra�� CONSTRUCTION LENDING AGENCY 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) AVCiv.C.) ..,.... j0,.. PLAN CHECKING FEE j;!j �-ti I_4 j %•,7 L; f+ 'Lender's Name PERMIT ISSUING FEE q'` J."..47 oxT Lender's Address I certify that I have read this application and state that the above TOTAL FEE 4113 information is correct. I agree to comply with all County ordinances and State laws regulating Electrical wiring, and hereby authorize representatives of this Cou enter upon the above•mentioned prop r inape tion pur sea. SEE REVERSE FOR EXPLANATORY LANGUAGE SIGN TUR PPL AN OR TE WORKER'S COMPENSATION DECLARATION • 20-0.019 DPW 9(89 - I hereby affirm that I have a'certificate of consent,to self insure, 7BAss3 APPLICATION OR ELECTRICAL PERMIT 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. . C01 FOR APPLICANT TO FILL IN JOB ESSmgA ..R Certified-co r-' b- furnished: EACH NO. FEE Y New Residential Bldgs.&Pools LOCY►LITY Q Certified copy is filed:with the county building'inspection ;1&2,Famllyi Sq.Ft. _ EST $. $ department: Multi-family Sq.Ft. CROSS ST. Date. _ Applicant Residential Swimming Pools ASSESSOR® MAP'BOOK PAGE PA EL :CERTIFICATE OF DCEMPTION FROM'WORKERS' FM NAME I. Outlets:.Rec.-Light Sw. COIiAPENSATION INSURANCE. - • - . . First 20 - - - - - (This.section need not be completed if the work.Involved,by the M AIL, permit is for one hundred dollars($100)6r'less.)' Total No. Additional ADDRESS- 3� I certify that In-the performance of the work for which•tli ermit CITY Tel:No.. �v . is-Issued,•1 shall not employ any person in any er•so;as to HECK become'subjectto'the Workers'Compensat, s. Lighting.Fixtures First 20 PLAN Date.. A ant' Total BRAN .. .No. -AdditionalADDRE 5 OR 20A;120V 6H CIRCUITS NOTICE TO AP.PLIC : If; after making this Certificate of ) CITY SS el.No, Exemption,you should become subject to the Workers'•Compensation ATO 10 INCLUSIVE EACH rovisions of the Labor Code,you must forthwith comply with such 11 TO 40 INCLUSIVE EACH PERMIT P Y P.Y APPLICANT provisions or this permit shall be deemed..revoked. 41.OR.MORE BRANCH CIRCUITS EACH } LICENSED CONTRACTORS DECLARATION ADDRESS} 15 OR 20A,208Y TO 27N LIGHTING`EACH CL AO I hereby affirm that I am licensed under,provisions of Chapter 8 �� (commencing with Section.7000)of Division 3 of the Businesa'-and CITY { L Professions Code,and my license is In full force and effect. RESIDENTIAL APPLIANCES UP TO.3HP LICENSE OR Powgr.Apparatus&Large Appliances REG.NUMBER ^y C - lass. C Q C License Numb 9 f 7 1. Size&Type HP,KW,KVA;or KVAR DISTRICT NO. P SSED BY H (; Up to 3.Incl: ' _ f Over 3 to 10.Incl. FINAL a Contractor Date r + Ove 10Incl; DATE V, r to 50 0 I'am.exempt.under.Sec. Over 50 to 100 Incl, . FINAL VALIDATION B:&P:C.for this reason' Y PlOver 100 Services,Swbd.,MCC WP:aneiboards-_ 0-200 Amp.Under 800 V Signature201 1000 Amp.•Under 000 V Over 1000.Atrip.or Over 600'V Exemption for eg.Maint,;Elect. SINGLE FAMILY Temp.Power Pole&Appurtenances HOME OWNER-BUILDERDECLARATION 1 hereby affirm that I am exempt from the Contractor's License Law Signlwlth One Branch Circuit for the following reason (Section 7031.5; Business and Professions Additional Sign'Branch Circuits Code); t+ . il;: MisclConduits&Conductors :I,as owner of the,property;will do the work and the structure i, is.not intended or offered for sale(Se ; (Section 7044, Business ' Other(See Complete Fee Schedule) �'•••- ' and Professions Code). ► C2% ti. `• `i.d s c CONSTRUCTION LENDING AGENCY I hereby affirm that there.is a construction le ency for the performance of the work for which this t Is Issued(Sec.3097, PERS IT FEE (Sub-Total) i Civ.C.) ?I: iii PLAN.CHECKING FEE, Lender's Name. syi{ + D _ :�� '1 PERMIT ISSUING FEE _11Z Lender's Address t 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 L e I _'s regulating'Electrical wiring, and hereby authorize ves of this County'to enter upon the above-mentioned r inspect' 4U-rp- ',' ,.- - .REOPAP . ••SEE REVERSE FOR EXPLANATORY LANGUAGE LICA R A DATE �f COUNTY OF LOS ANGELES TEMPLE CITY # 0508ELECTRICAL PERMIT . DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS `'EL_0508 9908160045 BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY'CA 91780 PHONE:. (626) 285-0488 EXT: GA D: FEES PAID B I• D . G-ADD ESS: , ON FILE 5803 ROSEMEAD $L FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 91780 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 OR: PROCESSED P -EXPIRES ON: TEMPLE CITY OPTOMETRY08/16/99 k UT- 02/12/00 ' OWNER: TEL. NO: FINAL DATE FINAL BY: CODE: _ CALAC INVESTMENT - 3709 SAN DIEGO, CA9211137 ffSGKrFfl0N PF WORK ELECTRItAL .fOR.NEW SIGN APPLICANT: O• A N S SIGNS (562) 287-8505- - 9845 87-8505- '9845 1/2 ALBURTIS AV SPECIAL CONDITIONS: SANTA FE SPRINGS, CA LES Co CONTRACTOR: TEL. 116. S ��/ APPROVALS DATE INSPECTOR SIGNATURE A N S SIGNS (310) 801-0543- �,� A�► 98451/2 ALBURTIS AVE LIC: NO TEMPEOIPOWER0 SANTA FE SPRINGS CA 90670 569180 C45 NDERGRO ND CONDUIT ARCHITECT 0 1€�iTO: - FE GRO D LIC. N /• 1111111 ROUGH CONDUIT LROUGH WIRING � D C W Gn-", K S IN WATER INE lu PLAST I C Y/N METAL Y/N U P N NO D O 0 0 Service The REPORT ID: DPR265 ROUTE TO: BS0508