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Home My Public Portal About5809 ROSEMEAD BLVD_Electrical__ WORKER'S COMPENSATION DECLARATION 200-0019 DPW 9189 I heretly�affirm that I have a certificate of consent to self insure, APPLICATION FOR ELECTRICAL PERMIT or ace flflcatf4of 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 EACH NO. FEE ❑ $ — $ LOCALITY Certified copy is filed with the county building inspection 1&2-Family,Sq.Ft. NEAREST department. Multi-family Sq.Ft. CROSS ST. fit:. r 1 •6�/�.. Date Applicant Residential SwlrQming Pools ASSESSOR MAP BOOK PAGE PARCEL CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec._Light Sw. OWNER OR COMPENSATION INSURANCE FIRM NAME First 20 (This section need not be completed if the work Involved by the permit is for one hundred dollars($100)or less.) Total No. Additional ADDRESS 20 •Sc,- I certify that in the performance of the work for which this permit CI L is issued, I shall not employ any person in any manner so as to PLAN C EC become subject to the Workers'Compensation Laws. Lighting Fixtures Fhst:20 APPLICANT 1 O Total No. Additional ADDRESS Date r Applicant ! OR 20A, NOTICE TO APPLICANT: If, after m g thi 15 120V BRANCH CIRCUITS ificate of CITY . Tel. Ia R() 7 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 APPLic e-70provisions 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 7M LIGHTING EACH a I �f� a (commencing with Section 7000)of Division 3 of the Business and CITY �� Tel V Professions Code,and my license is in full force and effect. REof SIDENTIAL APPLIANCES UP TO 3HP LICEN E OR 12 J? �y /� Power Apparatus&Large Appliances REO.NUMBER Cl; License Number 116? s 75- Llc.Class `-10 Size&Type HP,KW,KVA,or KVAR DISTRICT NO. p PROCESSED BY U Q g Up to 3 Incl. ��1),f IL Contractor ate v—r a^9 Z_ Over 3 to 10 Incl. DATE U) Over 10 to 50 Incl. .❑ –��„i VALIDATION I am exem oder Sec. Over 50 to 100 Incl. FINAL B.&P.C.for this reason Over 100 BY Services,Swbd.,MCC&Panelboards Date: 0-200 Amp.Under 800 V Signature 201-1000 Amp.Under 600 V ❑ Over 1000 Amp.or Over 600 V Exemption for Reg.Melnt.Elect. 2 SINGLE HOME OWNER-BUILDERLY Temp.Power Pole ci Appurtenances ACCT. T' 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 3307 59.55 Code): 1 ITEMS ❑ 1,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) TOTAL 59.55 and Professions Code). CHECK 59.55 CONSTRUCTION LENDING AGENCY CHANGE ■Q�) I hereby affirm that there is a construction lending agency for the HA I performance of the work for which this permit is issued(Sec. 3097, PERMIT FEE (Sub-Total) Civ.C.) PLAN,CHECKING FEE 0000-0061 8/18/92 Lender's Name �1 5069 1 AM 9�44PERMIT ISSUING FEE :911 ' 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' spection purposes. r SEE REVERSE FOR EXPLANATORY LANGUAGE e, SIGNA RE OFA I ANT OR AG DATE WORKER'S COMPENSATION DECLARATION 20.0019 DPW(12-91) APP� TIO O�GEL TR CAL PERMIT L1 I hereby affirm that I have a certificate of consent to self insure, 76A663 /r 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.) �1/► w �/f� Policy No. Company �+ /v[f I� FOR APPLICANT TO FILL IN JOB ❑ ADDRESS Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE LOCALITY 1 &2-Family,Sq.Ft. _ $ $ Certified copy is filed with the county b ilding inspection NEAREST department. y Multi-family Sq.Ft. CROSS ST. A I / —• AP plicant �/ Residential Swimming Pools ASSESSOR MAP BOOK PAGE PARCEL Date f OR CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec. Light Sw. FFIIRM AME COMPENSATION INSURANCE First 20 MAIL (This section need not be completed if the work involved by the179 to 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 p Y P Y APPLICANT provisions or this permit shall be deemed revoked. Power Apparatus&Large Appliances LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS 1 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. LICENSE OR a Class. Over 50 to 100 Incl. REG.NUMBER ��/ �, Over 100 DISTRICT NO. PROCESSE Y Q License Number (�_Lia Class rI ,�^� C a:r Services,Swbd.,MCC&Panelboards a V Contractor ate D�Z 0-399 Amp.Under 600 V DATE FINAL O F] I am exempt under Sec. 400-1000 Amp.Under 600 V ( d��3-`/ Z VALIDATION U W Over 1000 Amp.or Over 600 V FINAL B.&P.C.for this reason BRANCH CIRCUIT FEES BY 0) 15A,or 20A,120V,Lighting or Recept. Z �� 7y 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 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 WAditional Sign BrancpKCircuitsCode): (� -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) Civ.C.) - PLAN CHECKING FEE Lender's Name - PERMIT ISSUING FEE Lender's Address TOTAL FEE I certify that I have read this application and under penalty of purjury state r that the above information is correct. I agree to comply with all County ordinances and State laws regulating Electrical wiring,and hereby authorize representatA of this County enter upon the above-mentioned property folin purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE OF PERMITTEE DATE COUNTY OF LOS ANGELES TEMPLE CI1Y 4 0508 ELECTRICAL PERMIT DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS EL 0508 0406030001 BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 PHONE: (626) 285-0488 EXT: LEGAL ID: FEES PAID BUILDING ADDRES : ON FILE 5809 ROSEMEAD BL 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, C G1 OUTLETS-LGT,SW,RECP 120.00 OUT 174.00 TENANT: G2 LIGHTING FIXTURES 60.00 LGT 93.00 ISSUED ON: PROCESSED BY: PLAN BY: EXPIRES ON: BLOCKBUSTER TOTAL FEES 294.75 06/03/04 VG 11/30/04 OWNER: TEL. N0: FINAL DATE FINAL, BY: CEDE: CALAC INVESTMENT (858) 565-8333- 3709 CONVOY ST. SAN DIEGO, CA9211137DESCRIPTION OF WOP.K ELECTRICAL FOR T.I. APPLICANT: TEL. NO: FAST TRAK PERMIT SERVICE (909) 279-0604- SPECIAL CONDITIONS: CONTRACTOR: TEL. NO: APPROVALS DATE INSPECTOR SIGNATURE MAGNUM ENTERPRISES (714) 828-1191- 2515 W WOODLAND DR LIC. NO TEMPORARY POWER POLE ANAHEIM, CA 92801 436517/B UNDERGROUND CONDUIT _ ARCHITECT-OR-ENGINEER: TEL. NO: UFtR GROUND TARLOS AND ASSOCIATES (949) 250-4117- 17802 MITCHELL, NO. LIC. NO: ROUGH CONDUIT IRVINE, CA 92614 NONE ROUGH WIRING MAIN WATER LINE PLASTIC Y/N METAL Y/N TILITY COMPANY NOTTIFIED * ADDITIONAL DATA ON FILE REPORT ID: DPR265 ROUTE TO: BS0508