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WORKERS'COMPENSATION DECLARATION :so-001.9 DPW 3/87 APPLICATION FOR E 117RICAL PERMIT
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�:;heceby affirrr�that. I save a certificate of consent to self '�E
Irtii ure, or a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
or a certXcl copy thereof(Sec. 3800, Lab. C.)
Policy No. CompanyI FOR APPLICANT TO FILL IN JOB
❑Certified copy is hereby furnished. New Residential Bldgs. &Pools EACH NO. FEE ADDRESS
❑Certified co is filed with the county building inspec- I 1 '&2-Family,S Ft. $ — $ LOCALITY
PY � tY 9 � P Y� q•
tion department. I Multi-family Sq. Ft. — I NEAREST r
j i CROSS ST.
Date Applicant Residential Swimming Pools OWNER OR ^^� n
FIRM NAME c /'T L
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec a Light2__Sw.a— / MAIL p
COMPENSATION INSURANCE I p� First 20 D (! ADDRESS1 , 7
(This section need not be completed If the work involved by Total No.1�— Additional I CITY 11 - G` Tel. No. JITthe permit is for one-hundred dollars($100)or less.) �' i PLAN CHECK
I certify that in the performance of the work for which this ( APPLICANT
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. I Lighting Fixtures First 20 ADDRESS
Additional
Date Applicant Total No. .�_ ti CITY Tel. No.
NOTICE TO APPLICANT.: If, after making this Certificate of � Fixed Appliances Not Over 1 HP PERMIT
Exemption, you should become subject to the Workers' Range Heater—D.W. — APPLICATION
Compensation provisions of the Labor Code, you must forth- I Oven — bryer —W.M.— ADDRESS
with comply with such provisions or this permit shall be Top — FAU —W.H. —
deemed revoked. CITY Tel. No.
Disp.
Hood — Fan —Other—
LICENSED CONTRACTORS DECLARATION — Room AirCond. LICENSE OR I hereby affirm that.l am licensed under provisions of Chapter 9 REG. NUMBER Class.
(commencing with Section 7000)of Division 3 of the Business Power Apparatus&Large Appliances ' DISTRICT NO. RRQQESSED BY d
and Professions Code,and my license is in full force and effect. � a-
Size&Type HP, KW, KVA, or KVAR ems'
License Number Lic. Class I Up to 1 Incl. FINAL U
DATE " VALIDATION
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Contractor Date Over 1 to 10 Incl.Over 10 to 50 Incl. FINAL 0
❑ I am exempt under Sec. Over 50 to 100 Inc. BY ��� a�+B--- W
B.&P.C. for this reason i Over 100 a
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Date:
• Services, $wbd., MCC 8 Panelboards Z Z
0-200 Amp. Under 600 V
Signature 201 - 1000 Amp. Under 600 V
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Over 1000 Amp. or Over 600 V
Exemption for Reg. Maint. Elect.
SINGLE FAMILY I Temp. Power Pole&Appurtenances
HOMEOWNER-BUILDER DECLARATION Sign with One Branch Circuit y
I hereby affirm that I am.exempt from the Contractor's License Additional Sign Branch Circuits' 1 °a
Law for the following reason (Section 7031.5, Business and g _ _
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Professions Code): ;3�;` � 0
� Misc. Conduits&Conductors
I(Z51�1, 6s owner of the property, will do the work and-the f TTEN'�
Structure is not intended or offered for sale(Section 7044, Other(See Complete Fee Schedule)—
Business and Professions Code). TOTAL _5� . 20
• CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for '�`'JH �t
the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) .�:
(Sec. 3097, Civ. C.).
PLAN CHECKING FEE '
Lender's Name 01000-000 t 2311'13/5,1
PERMIT ISSUING FEE �3 I _.�
Lender's Address f , 0051 .. AN t:6'
I certify that I have read this application and state that the TOTAL FEE
above information is correct. I agree to comply with all County i
ordinances and State laws regulating Electrical wiring, andi
hereby authorize representatives of this County to enter upon I
the abovenmentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
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S' nfi re of Permitt Date ®s
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COUNTY OF LOS ANGELES TEMPLE CITY �� # 0508 ELECTRICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS EL 0508 9903290029
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780%
PHONE: (626) 285-0488 EXT:
LEGAL D: FEES PAID BUILDrNG ADDRESS:
BK: 246 PG: 71 PC: 2 9211 WEDGEWOOD ST
FEE DESCRIPTION: W QUANTITY: UOM: AMOUNT: TEMP CA 917802437
ASSESSOR OR ON UMBER: NEAREST CROSS STREET: ENCINITA
8588-001-028 Al PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 596 GRID: J4 LOCALITY: TEMPLE CITY
LA 100 AMP PANELS, MCC 1.00 PAN 38.85
TOTAL FEES 66.60 ISSUED 0PROCESSED BY: P A B : EXPIRES 0 :
03/29/99 UT 03/29/00
OWNER: TEL. N0: FINAL DATE FINAL C DE:
MAGRO CAL C;VALERIE J (
9207 WEDGEWOOD ST /
TEMP 917802437 DESCR P IO W K
INSTALLATION OF JEW 100 SERVICE PANE
APPLICANT:
TEL. 0: /
SAME AS OWNER
SPECIAL CONDITIONS:
ANGELES co
CONTRACTOR:
OWNER TEL. NO: - Q �nl/A� APPROVALS DATE INSPECTOR SIGNATURE
SAME LIC. NO / S" TEMPORARY OWER POLE
UNDERGROUND CONDUIT
ARCHITECTOR ENGINEER: E 0: - / UF8R GROUND
LIC. N0: J ' — i �tt;;� ROUGH CONDUIT
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11 u l ID �� �r uA�O IFVI' � PLASTIC Y/NLIMETAL Y/N
i— /1 00UTILITY COMPANY NOTIFIED :w IE—
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REPORT ID: DPR265 ROUTE TO: BS0508