HomeMy Public PortalAbout5312 TEMPLE CITY BLVD_Electrical__ WORKERS'COMPENSATIONDECLARATION 78'4889
CE-808G (2-80) APPLICATION FOR ELECTRICAL PERMIT
I•hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES T BUILDING AND SAFETY
insure,or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec 3800.
Policy No Compen
• FOR APPLICANT TO FILL IN JOB
ADDRE
IiS�Ii New Residential Bldgs &Pools
EACH NO FEE
Il1LlCertified copy to hereby furnished 1 &2 Family,Sq Ft S — S LOCALITY
00 T Certified copy is filed with the un building inspection Multi-family Sq Ft CROSS ST
department Residential Swimming Pools OWNER OR
FIRM NAM
Date �pphcentLlvs.�� Outlets Rec_Light_Sw _ ADDRESS 3 Ell `-'
Fust 20 I _ t
CERTIFICATE OF EXEMPTION FROM WORKERS Total No Additional CITY Tel No ).
COMPENSATION INSURANCE PLAN C CK all
(This section need not be comppleted tflthe work involved APPLICANT n V
by the perms[ u for one hundred dollars (3100) or leas)' Lighting Fixtures Flirt 20 ADDRESS S
Total No Additional Q
I permit
that the performance of the work for which this Fixed Appliances Not Over 1 HP CITU Tel No 1(-J
permit m issuedd person 1 shell not employ any pern any manner PERMIT W
so as to become subject to the Workers' Compensation Laws Range_ Heater_D W _ APPLICANT N
` Oven — Dryer_W M _ ADDRESS Q Z_
Date Applicant Top _ FAU _W H _ CITY Tel No
Hood _ Fan —Other— -
2,0
NOTICE TO APPLICANT If, after making this Certificate of Disp _ Room Air Cond_ C R
Exemption, you should become subject to the Workers' REG NUMBER Class
Compensation provisions of the Labor Code you must forth Power'Apparatus& Large Appliances DIST RIOT NO PRO ES I BYE
with comply with such provisions or this permit shall be Size&T r
deemed revoked Type HP,KW,KVA,or KVA �( i1
1 Up to 1 Incl FINAL C�
Over 1 to 10 Inc] DATE /,9 -45 Pr VALIDATION i
LICENSED CONTRACTORS DECLARATION Over 10 to 50 Incl )
I hereby sff[rm that 1 am licensed under provisions of Chapter Over 50 to 100 Inc FINAL
Y AL
9 (commencing with Section 7000)of Division 3 of the Bust Over 100 �r
nese and Professions Code, and my license is in full force and
affect Services
License Number lama 0-200 Amp Under 600 V -2 7 y
l() 201-1000 Amp Under 600 V / /
1Conlract aTa AWIF: Over 1000 Amp or Over 600 V
HOM OWNER BUILDER DECLARATION Temp Power Pole&Appurtenances
I hereby affirm that I am exempt from the Contractor's Sign with One Branch Cirmit
License Law for the following reason (Section 7031 S Busi Additional Sign Branch Circuits 21 5 2 0 A
ngss and Professions Code)
Mise Conduits&Conductors # a • • • • 2
1, as owner of the property, will do the work and the Other (See Complete Fee Schedule)—
structure is not intended or offered for sale (Section Zj• • 1 200
i
7044, Business and Professions Code)
CONSTRUCTION LENDING AGENCY la •
- 120061 hereby affirm that there is a construction lending agency `
for uhe performance of the work for which this permit is PERMIT FEE (Sub Total) I Q 1 3-8 1
issued(Sec 3097 Civ C) i
Lender s Name PLAN CHECKING FEE (One Fourth Permit Fes) '
Lender's Address PERMIT ISSUING FEE
I certify that I have read this application and state that the TOTAL FEE a-
above information is correct I agree to comply with all County
ordinances and State laws regulating Electrical wiring, and
hereby aptkonze representatives of this County to enter upon
the abopurposes SEE REVERSE FOR EXPLANATORY LANGUAGE
'191eture of Perini ee Date
I i
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 ELECTRICAL PERMIT
DEPARTMENT OF PUBLIC FORKS 9701 LAS TUNAS EL 0508 1109200032
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE (626) 285-0488 EXT
LEGAL ID FEES PAID BUILDING ADDRESS
ON FILE 5312 TEMPLE CITY BL
] IFEE DESCRIPTION QUANTITY UOM AMOUNT TEMP CA 917803148
ASSESSOR INFORMATION NUMBER I NEAREST CROSS STREET
8589-001-013 IA1 PERMIT ISSUANCE FEE 27 80 I THOMAS PAGE 597 GRID A4 LOCALITY TEMPLE CITY Cl
IG1 OUTLETS-LGL SN RECP 1 00 OUT 1 90
(TENANT I TOTAL FEES 29 70 ISSUED ON PROCESSED BY PIAN BY
_ I _ - -- - 109/20/11 - - SR - - -
I
TOWNER TEL NO (FINAL DATE FINAL BY CODE
IKEDROSKI, BERNICE/WILLIA M (626) 286-8107- ]
5312 TEMPLE CITY BL
TEMP 917803148 (DESCRIPTION OF WORK
ONE GPI
I1 �
(APPLICANT TEL NO
BROTMAN, IFAT (818) 987-7277- (/
ISPECIAL. CONDITIONS
I I
ICONTRACTOR TEL NO I (APPROVALS DATE INSPECTOR SIGNATURE
ISO CAL,PREFERRED BUILDERS INC (323) 464-4663- 1
16423 YUCCA STREET LIC NO - (TEMPORARY POWER POLE
(HOLLYWOOD, CA 90028 956938 B I I 1-1-
I I I
I ]UNDERGROUND CONDUIT
(ARCHITECT OR ENGINEER TEL NO - IUFER GROUND
LIC NO TROUGH CONDUIT I
I I 1 -1-1
] , IROUGH WIRING II
] (MAIN WATER LINE
PLASTIC YIN METAL YIN I
UTILITY COMPANY NOTIFIED( I
] I
I I
EXPIRED
] I I I
I I I I ] ]
I IRE PORT ID OPR265 ROUTE TO 850508
I I