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HomeMy Public PortalAbout5825 ROSEMEAD BLVD_Electrical__ I` WORKER'S COMPENSATION DECLARATION 20.0019 DPW(12-91) 1 herebpaffirmlithat I have a certificate:of consent to self Insure, 76A683 APPLICATION FOR ELECTRICAL PERMIT or a certificate of fvorker's Compensation Insurance, or eitifled 1, COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS BUILDING,AND-SAFETY DIV: copy thdreof(Sec.'18800007Lab.C.) " Policy No. /S�+ Company J� FOR APPLICANT TO FILL IN iOB 1 OI 0 fed copy is hereby furnished. `7—� NO. EACH FEE ADDREss' OG 1 New Residential Bldgs.&Pools _ $ $ LOC/LITY Certified copy is filed with the county building Inspection 1.&2-Family,Sq.Ft. d a ent Multi-family Sq.Ft. — CROSS ST. 1 Residential Swimming Pools ' y� ASSESSOR Date Applica�� MAP BOOK Eq PAGE � PARCEL CERTIFICATE COMPENS COMPENSATIONON FROM INSURANCE.RKERS' Outlets:Rec. Light Sw. / p0 FIRM NAME t•20 i G (This section nied not.be completed if the work involved by the 1 ADDRIL ESS permit is for one hundred dollars($100)or less.) Total No. Additional O � I certify that in.the performance of the work for which this.permit / CITYi 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 FixturesIrst 20 APPLICANT Total No. Additional illADDRESS 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 G7 �N� �r� provisions-or this:permit shall be deemed revoked. Power Apparatus&Large Appliances APPLICANT 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. CITY yJ, Tel.No. (commencing with Section 7000)of Division 3 of-the Business and 1, //Af /i!-a /Q W_ Professions Code,and my license is in full force and effect. Over 10:to 50 Incl. ,s /o , LICENSE OR !� t7y� class.4— }a Over 50 to 100 Incl. REG.NUMBER .J V Over 100 DISTRICT NO. PR C ED BY V License Number Lic.Class f! Services,Swbd.,MCC&Panelboards 1' 4 Contractor/ _•—�'Yyte '� 0-399 Amp.Under 600 V pA 0 1 am exempt under Sec. 400-1000 Amp.Under 600 V ;� 3 Over 1000 Amp.or Over 600 V TINA VALIDATION W B.&P.C.for this reasonBRANCH CIRCUIT FEES BY I (n Date: 15A,or 20A,120V,Lighting or Recept. Z_ Signature 1 To 10 Branch Circuits 11 To 40 Branch Circuits 47 Or More Branch Circuits Exemption for Reg,Maint.Elect. 15A,2DA,2D8V To 277V-UghOng Br.Circuits 2 SINGLE FAMILY Temp.Power Pole&Appurtenances "" ' - - �°• HOME OWNER-BUILDER DECLARATION I• ACCTA 'I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit _ a� 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) �• TOTAL •. ';-o 8a' 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) �p Civ.C.) PLAN CHECKING FEE jQ —�Q�� 3/25/06 Lender's Name 1 PERMIT ISSUING FEE 8868 1 A!illu-N Lender's Address - I 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 1 for ins tion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE JAP43 RE FPERMnTEE DATE" r ' WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12-91) 78A683 APPLICATION FOR ELECTRICAL PERMIT I herebN affirm that I have a certificate of consent to self insure, or a certificate of dvorker's Compensation Insurance,ora ertified COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS BUILDING AND SAFETY DIV. copy thdreof(Sec.3800 Lab.C.) �,�.� Policy 7�.5"S ��company FOR APPLICANT TO FILL IN JOB JJ ADDRESS OG V ed copy is hereby furnished. `7'�9� New Residential Bldgs.&Pools NO. EACH FEE LOCALITY 7 r 1&2-Family,Sq.Ft. — $ 5 `� Certified copy is filed with the county building inspection _ NEAREST dgpa en Multi-family Sq.Ft. CROSS ST. Date Applica „ - +� � Residential Swimming Pools ASSESSOR MAP BOOK PAGE PARCEL CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER OR �y� COMPENSATION INSURANCE Outlets:Rec. Light Sw. FIRM NAME /f�far/�4 ®�/� sf 20 This section need not be completed If the work Involved b the MAIL permit is for one hundred dollars($700)or less.) y Total No. Additional ADDRESS 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 become subject to the Workers'Compensation Laws. Lighting Fixtures 'ret 20 APPLICANT Total No. Additional 4 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 Power Apparatus&Large Appliances APPLICANT / provisions or this permit shall be deemed revoked. LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS /P6?,j9p,r fR11— 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 ,O%�e. � X.Tel.No. �� 7 Professions Code,and my license is in full force and effect. Over 10 to 50 Incl. ��0 >_LICENSE OR ✓^�© Class. d Over 50 t0 100 incl. REG.NUMBER 3 License Number /Up Lie.Class Over 100 DISTRICT NO. PRC SED BY V ,moi �d r _ Services,Swbd.,MCC&Panelboards P /C/N� erzgzl' -� 0-399 Amp.Under 600 V FINAL p Contractor Date DATE 400-1000 Amp.Under 600 V �f l F1 am exempt under Sec. 7 7�� VALIDATION W Over 1000 Amp.or Over 600 V FINAL B.&P.C.for this reason BRANCH CIRCUIT FEES BY a Date: 15A,or 20A,120V,Lighting or Recept. Z 1 To 10 Branch Circuits Signature 11 To 40 Branch Circuits F141 Or More Branch Circuits Exemption for Reg.Maint.Elect. ISA,20A,208V To 277V Lighting Br.Circuits 2 FAMILYSINGLE Temp.Power Pole&Appurtenances HOME OWNER-BUILDERDECLARATION ACCTn8 I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit 1�e for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits 53074�-yt V7 4 35 Code): 1 ITE ❑ I,as owner of the property,will do the work and the structure Misc.Conduits&Conductors y �. is not intended or offered for sale(Section 7044, Business Other(See Complete Fee Schedule) TOTAL oa and Professions Code). c CONSTRUCTION LENDING AGENCY [� _ I hereby affirm that there is a construction lending agency for the rl performance of the work for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total) �p Civ.C.) PLAN CHECKING FEE 33/25/93 Lender's Name PERMIT ISSUING FEE 88633 1 AN110-54 Lender's Address10, 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 ins tion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE RIF PERMITTEE D E COUNTY OF LOS ANGELES TEMPLE CITY # 0508 ELECTRICAL PERMIT DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS EL 0508 0208080040 BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 PHONE: (626) 285-0488 EXT: LEGAL 10: FEES PAID UILDING ADDRESS: ON FILE 5825 ROSEMEAD SL FEE DESCRIPTION: QUANTITY: LION: AMOUNT: TEMP CA 91780 ASSESSORMB R: NEAREST CROSS STREET: ROSEMEAD 5397-012-043 Al PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: GRID: LOCALITY: TEMPLE CITY ftl SIGNS, OUTLINE LGT 1'.00 SIG 38.85 T TOTAL FEES 66.60 ISSUED ON: PROCESSED EXPIRES ON: 08/13/02 JK 02/09/03 OWNER: TEL. NO: FI E, FINAL BY: CODE: CALAC INVESTMENT 3709 SAN DIEGO, CA9211137 DESCRIPTION Of WORK ELECTRICAL FOR SIGN APPLICANT: TEL. NO: SIGN ART CO (626) 287-2512- 423 S CALIFORNIA ST SPECIAL CONDITIONS: SAN GABRIEL CONTRACTOR: TEL. N0: APPROVALSAECTOR SIGNATUR SIGN ART CO. (626) 287-2512- INSP 423 S CALIFORNIA LIC. NO0 SAN GABRIEL CA 91776 491427 C45 y'�' ' \t',' LE UNDERGROUND CONDUIT ARCHITECT OR ENGINEER: 0: ' I�� - ', R GROUND LIC. N0: r' :- = + ROUGH CONDUIT MAIN WATER LINE PLASTIC Y/N METAL Y/N - - -- -- UTILITY COMPANY NOTIFIED' REPORT ID: DPR265 ROUTE TO: BS0508