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Home My Public Portal About5329-5331-5333-5335 VILLAGE CIRCLE DR_Electrical__ WORKER'S COMPENSATION DECLARATION 76A663 DPW(12 91) APPLICATION F®® ELECTRICAL t ECTRIC A L PERMIT I hereby affirm that I have a certificate of consent to self insure, L4° tl EIY! A Il 6� is 9 Ii i f1 GY7 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.) w¢/ wo ��`�/ lc S1//7A F FOR APPLICANT TO FILL IN ADDRESS Pol o. Company ❑ Certified co is hereby furnished. NO. EACH FEE PY� Y New Residential Bldgs.&Pools _ $ $ LOCALITY I(J. Certified co is filed with the count building inspection 1 &2-Family,Sq.Ft. PY Y 9 P NEAREST department/.' yy•� Multi-family Sq.Ft. CROSS ST. Date,3-2,9-C 3 •Applicant ��L S�/ Residential Swimming Pools ASSESSOR ✓ MAP BOOK PAGE PARCEL CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER OR COMPENSATION INSURANCE Outlets:Rec._Light Sw. ,/ A FIRM NAME � � d+ First 20 Q MAIL (This section neeh n d d completed 0 the work Involved by the Total No. Additional ADDRESS�3a permit is for one hundred dollars($100)or less.) ' I certify that in'the performance.of the work for which this permit CITY ' �� Tel.No. yJ:_apd X is issued, I shall not employ any.person in any.manner so as to PLAN CHECK become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 APPLICANT' Total No. Additional • ADDRESS _ Date Applicant RESIDENTIAL APPLIANCES NOT OVER 3 HP. NOTICE TO'APPLICANT: If, after making this Certificate of CITY Tel.No. Exemption,you should become subject to the Workers'Compensation OTHER APPLIANCES NOT OVER 3 HP. / provisions of the Labor Code, you must forthwith comply with such PERMIT �L provisions or this permit shall be deemed revoked. Power Apparatus.&Large Appliances LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS -?V 74 og& I hereby affirm that I am licensed under provisions of Chapter 9 Over 3 to 10 Incl. CIN T.I.No. (commencing with Section 7000)of Division 3 of the Business ande,� Over 10 to 50 Incl. Professions Code,and my license is in full force and effect. � LICENSE OR O AJ }' 44 Over 50 to 100 Incl. REG.NUMBER 4 j a a CIS'G�� O nsC� Over 100 DISTRICT NO. PR ESSED BY U License Number •wJ c2 `T O Lic.Class ,� ` /_.f ¢ Services,Swbd.,MCC.&Panelboards �' ®� cc Contractor �` Date�/� O 01 0-389 Amp.Under B00 V DATE 1- 400-1000 Amp.Under 600 VVALIDATION LLI I am exempt under Sec. Over 1000 Amp.or Over 600 V FINAL 11 B.&P.C.for-this reasonBRANCH CIRCUIT FEES BY Z Date: 15A,or 20A,120V,Lighting or Recept. — 1 To 10.Branch Circuits Signature 11 To 40 Branch Circuits El 41 Or More Branch Circuit's Exemption for Reg.Maint.Elect. 15A,20A,208V To 277V Lighting Br.Circuits SINGLE FAMILY Temp.Power Pole&Appurtenances HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit °$ 1-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 3307 40.05`:r�-;; ,.�.5 Code): 'ITEMS ElMisc.Conduits&Conductors ,f I,as owner of the property,will do the work and the structure c is not.intended or offered for sale(Section 7044, Business Other(See Complete Fee Schedule) TOTAL ,O T AL 4� m 05 Pol- and Professions Code).. CHECK CONSTRUCTION LENDING AGENCY CHANGE I hereby affirm that there is a construction lending agency for the '; I performance of.the work for which this permit is issued(Sec. 3097, PERMIT FEE (Sub-Total) Civ.C.) PLAN CHECKING FEE 00130-0001 3/31/93 Lender's Name �� 8963 1 AM 10 c 48 ' PERMIT ISSUING FEE , Lender's Address I certify that I have read this application and under'perialty of purjury state TOTAL FEE Q, O 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 t enter on the above-mentioned property - for inspe pur as. a SEE REVERSE FOR EXPLANATORY LANGUAGE 30-// DAT SIG URE.OF ERMI E 76.0669-CE60810/74 TEMPLE CITY APPLICATION FOR ELECTRICAL PERMIT Circle or. COUNTY OF LOS ANGELES DEPARTMENT OF COUNTY ENGINEER JOB 20 5335 33 31 29 N. Vllla BUILDING AND SAFETY DIVISION LOCALIT 2-2 NEAREST FOR APPLICANT TO FILL IN CROSS ST, OUTLETS NO. EACH 'FEE OWNER OR RECEPT.102 S. $ FIRM NAME JqOej Bald&dn MAIL LIGHT 66 TOTAL FIRST 20 20 25 8 .00 ADDRESS 5302 Baldwin Avenue SWITCH 100 268 OVER 20 CITY Temple City TEL. NO.448-3907 48 .IO 37.20 PLAN CHECK LIGHTINGTOTAL 1 FIRST 20 20 25 8 00 APPLICANT FIXTURES ) 66 OVER 20 46 .10 6 90 ADDRESS RESIDENTIAL APPLIANCES CITY TEL. NO. PERIT RANGE DRYER_WTR. HTR. APPLICANT ITII McGee Electric Inco STA. COOK DISP. 4 F.A.U. 4 ADDRESS SPACE HTR, L�t11R COND.---,— CITY Pomona TEL. N0, 628-1221 CLOTHES WASH. DISHWASH. LICENSE G NUBENMER 153378 CLASS.0-10 FAN-1410THER 4 34 1.005 00 1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION ,AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY MOTORS, TRANSFORMERS RATING WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING IND. HEATERS, ETC. HP. KW.KVA. ELECTRICAL WIRING. SIZE & TYPE OVER TO 1 HEREBY CERTIFY THAT i AM PROPERLY REGISTERED AND/OR 0 - 1 1.00 LICENSED AS REQUIRED BYLOS ANGEL S COUNTY AND STATE OF }. .CALIFORNIA OR THAII 1,4A THE LEG OWNER OF THE ABOVE 77V C C 1 - 10 4 3.00 19 00 DESCRIBED ROPER Y V PERMITEE 10 - 50 5.00 SIGNATURE V 50 - 100 10.00 W DISTRICT N0. ES D BY y 100 - 500 15.00 r OCR z SIGN, GAS SIGN AND ONE CIRCUIT 5.00 APPROVALS DATE INSPECTOR'. GNATURE TUBE, OR MARQUEE ADDITIONAL CIRCUITS 1.00 TEMP. POWER POLE SERVI CE NOT OVER 600 VOLTS OR 200 AMP 4 3.00 JE 00 UNDERSLAB WORK S ERVI CE OVER SOO VOLTS OR 200 AMP 10.00 ROUGH CONDUIT .s� TEMP SERVICE,POLE,&APPURTENANCES 5.00 WIRING -, -?s TEMP LIGHT OR RECEPT. SYSTEM 3.00 FIXTURES POWER AUTHORIZED UTILITY CO. NOTIFIED FINAL PERMIT FEE (SUB TOTAL) 147.10 NOTES; PLAN CHECK FEE PERMIT ISSUING FEE 3.00 4 150 TOT�4L FEE 1'551.60 PLAN CHECK VALIDATION CK. M.O. CASH PERMIT VALIDATION CK. M.O. CASH 8 4 3 u moo 17 2 �. 5 1.6 0 ,6:,-d SEE BACK OF APPLICATION FOR COMPLETE SCHEDULE WORKERS'COMPENSATION DECLARATION toiel. APPLICATION FOR ELECTRICAL PERMIT . I hereby affirm that I have a certificate of consent to self �E"tE-806� _ insure, or a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELESI BUILDING AND SAFETY or a certified copy thereof(fiat. 3800, Lab. C.) �� I Policy No. Company FOR APPLICANT-TO FILL INJOB r ❑ 1 EACH NO. FEE ADDRESS _ Certified'copy is hereby furnished. New Residential Bldgs. &Pools �L ❑ Certified copy is filed with the county building inspec- ' 1 &2-Family, Sq. Ft. $ — $ LOCALITY tion department. Multi-family Sq. Ft. — NEAREST , Residential Swimming Pools CROSS ST. Date Applicant. OWNER O FIRM NAME' CERTIFICATE OF EXEMPTION FROM WORKERS'- Outlets': { MAIL COMPENSATION INSURANCE Outlets: Rec Light Sw. .� ADDRESS s section neenote completed If,the work involved b First 20 (Thitineed b p Y Total No. Additional CITY C.C el. No. the permit Is for one.hundred dollars(;100)or less.) I certify that in the performance of the'work for which this PLANG4NTK permit is issued, I shall not employ an n any anner O so as to become subject to the War. eris Lighting Fixtures First 20'. ADDRESS Total No.— Additional CITY Tel. No. Dat pplica Fixed Appliances Not Over 1 HP PERMIT NOTICE TO APPLI ANT: If, after making thiI er i icate of APPLICANT Exemption, you should become subject to the Workers' Range_ Heater_D.W. — Compensation provisions of the Labor Code, you must forth- Oven —Dryer —W.M.— ADDRESS ' with comply with such provisions or this permit shall be Top _ FAU —W.H. —. CITY Tel. ni�7 o deemed revoked. Hood _ Fan _Other_ LICENSED CONTRACTORS DECLARATION- LICE.S R. y Disp. _ Room Air Cond. REG..NUMBE Class.G I hereby affirm that lam licensed under provisions of Chapter 9 /Q (commencing with Section 7000)of Division 3 of.the Business DISTRICT NO. PROC SED BY ` and Professions'Code,and my license is in.full f6rce and effect. Power Apparatus&Large Appliances Size&Type HP, KW, KVA, or KVAR• D a License Number Lic. ClassUp to 1 Incl. FINAL / ' Over 1 to 10,Incl. DATE VALIDATION 0 Contractor Date Over 10 to:50 Incl. .FINAL V ❑ I am:exempt under Sec.. Over 50'to 100 Inc. BY AM B.&P.C. for this reason Over 100 Services, Swbd.,.MCC&Panelboards ® �' .Date:. 0 -200 Amp. Under 600 V 14 Signature 201 - 1000 Amp. Under 600 V ❑ Over 1000 Amp. or Over 600 V 1.1103 C' (�•� �� Exemption for Reg. Maint. Elect. SINGLE FAMILY -Temp. Power Pole&Appurtenances e o 0 o o 2 HOMEOWNER-BUILDER DECLARATION. Sign with.One Branch•Circuit ' I hereby affirm that'I am exempt.from the Cont'ractor's License additional Sign Branch Circuits 2 ' c E n C Low-for the following reason (Section 7031.5, Business and Professions Code):. 'o Q o ❑ I, as owner of theproperty, will'do the work and the Misc. Conduits&Conductors ' ® r3 f2—ALL structure is not intended or offered for sale (Section Other(See Complete Fee.Schedule)_ 7044, Business 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 PERMIT FEE (Sub-Total) d (Sec. 3097, Civ. C.). + PLAN CHECKING FEE Lender's Name PERMIT ISSUING FEE IdO Lender's Address �/' - 1.certify that I ha.ve'read,this application and state that the TOTAL FEE O d,0 above information is correct. I agree to comply with all County ordinances an fate laws regulati Electrical.wiring, and hereby. + represe unty enter upon C the ab tioned r tion. poses. SEE REVERSE FOR EXPLANATORY LANGUAGE 3.. z-' On ate • '