HomeMy Public PortalAbout5721 OAK AVE_Electrical_11/26/2003_COUNTY OF
LOS ANGELES
TEMPLE CITY
#
0508
ELECTRICAL PERMIT
• DEPARTMENT OF
PUBLIC WORKS
9701 LAS TUNAS
EL 0508 0311260021
BUILDING AND SAFETY
/ LAND DEVELOPMENT
TEMPLE CITY CA
91780
PHONE: (626) 285-0488 EXT:
LEGAL 10:
FEES PAID
BUILDING ADDRESS:
TR: 6561 LT: 730
UN: .002
5721 OAK AV
FEE DESCRIPTION:
QUANTITY: UOM:
AMOUNT:
TEMP CA 917802431
ASSESSOR INFORMATION NLMBER:
NEAREST CROSS STREET: LIVE OAK
8587-005-005
Al PERMIT ISSUANCE FEE
27.75
THOMAS PAGE: 596 GRID: J3
LOCALITY: TEMPLE CITY
G1 OUTLETS-LGT,SW,RECP
8.00 OUT
15.60
TENANT:
G2 LIGHTING FIXTURES
3.00 LGT
5.85
ISSUED ON: PKuLCJJCV BY: PLAN BY:
EXPIRES ON:
TOTAL FEES
49.20
11/26/03 JK
05/24/04
OWNER:
TEL. NO:
FINAL DATE FINAL BY:
CODE:
PORTER SCOTT
-
5721 OAK AV
TEMP 917802431
DESCRIPTION OF WORK
ADD BEDROOM
APPLICANT:
TEL. NO:
MASTER REMODELERS
(626) 960-2951-
2149 GARVEY AV NORTH
SPECIAL CONDITIONS:
WEST COVINA 91790
CONTRACTOR:
TEL. NO:
APPROVALS DATE
INSPECTOR SIGNATURE
MASTER REMODELERS
(626) 960-2951-
2149 W. GARVEY AVE NORTH
LIC. NO
TEMPORARY POWER POLE
WEST COVINA, CA 91790
622749 HIC
UNDERGROUND CONDUIT
ARCHITECT OR ENGINEER:
TEL. NO:
UFER GROUND
LIC. NO:
ROUGH CONDUIT
ROUGH WIRING
MAIN WATER LINE
PLASTIC Y/N METAL Y/N
UTILITY COMPANY NOTIFIED sJ Z
1
* ADDITIONAL DATA ON FILE
REPORT ID: DPR265 ROUTE TO: SS0508
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions
of Chapter 9 (commencing with Section 7000) of Division 3 of the Business
and Professions Code, and my license is in full force and effect.
License CI s &L-ic.No.
Contractor's Signature 'DA16
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the
Contractors License Law for the following reason (Sec. 7031.5, Business
and Professions Code: Any city or county which requires a permit to
construct, alter, improve, demolish, or repair any structure, prior to its
issuance, also requires the applicant for such permit to file a signed
statement that he or she is licensed pursuant to the provisions of the
Contractors License Law (Chapter 9 (commencing with Section 7000) of
Division 3 of the Business and Professions Code) or that he or she is
exempt therefrom and the basis for the alleged exemption. Any violation
of Section 7031.5 by any applicant for a permit subjects the applicant to a
civil penalty of not more than five hundred dollars ($500).):
❑ 1 am exempt under Sec. , B.& P.C. for this reason:
[ Electrical, Plumbing & Sewer Permits Only ]
❑ I, as owner of the property, will do the work, and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions Code:
The Contractors License Law does not apply to an owner of property who
builds or improves thereon, and who does such work himself or herself,
provided that such improvements are not intended or offered for sale. If,
however, the building or improvement is sold within one year of completion,
the owner -builder will have the burden of proving that he or she did not
build or improve for the purpose of sale.).
[ All Other Permits j
❑ I, as owner of the property, or my employees with wages as their sole
compensation, will do the work, and the structure is not intended or offered
for sale (Sec. 7044, Business and Professions Code: The Contractors
License Law does not apply to an owner of property who builds or improves
thereon, and who does such work himsel(or herself or through his or her
own employees, provided that such improvements are not intended or
offered for sale. if, however, the building or improvement is sold within
one year of completion, the owner -builder will have the burden of proving
that he or she did not build or improve for the purpose of sale.).
❑ I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business and Professions
Code: The Contractors License Law does not apply to an owner of property
who builds or improves thereon, and who contracts for such projects with
a contractor(s) licensed pursuant to the Contractors License Law.).
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a certificate of consent to self -insure for
worker's compensation, as provided for by Section 3700 of the Labor
Code, for the performance of the work for which this permit is issued.
❑ 1 have and will maintain worker's compensation insurance, as required
by Section 3700 of the Labor Code, for the perfor ance of the work for
which this permit is issued. My worker's compensa on insurance carrier
and policy number are:
Carrier 14 1.%✓Lr°
Policy Number (� v 0'-�1� f v-
❑ 1 certify that in the performance of the work for which this permit is
issued, I shall not employ any person in any manner so as to become
subject to the worker's compensation laws of California, and agree that if
should become subject to the worker's compensation provisions of
Section 3700 of the Labor Code, I shall forthwith comply with those
provisions.
Applicant Signature Date
WARNING: FAILURE TO SECURE WORKER'S COMPENSATION
COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER
TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED
THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF
COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3706
OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES.
LOBBYIST ORDINANCE CERTIFICATION
Complete this section for permits in
unincorporated Los Angeles County only ]
This is to certify that I, as permit applicant, am familiar with the requirements
of Los Angeles County Code Chapter 2.160 et seq., (relating to the Los
Angeles County Lobbyist Ordinance) and that all persons acting on behalf
of myself complied and will continue to comply therewith through the
application process.
Applicant (Print Name) Applicant Signature
JOB ADDRESS
LOCALITY
HAZARDOUS MATERIAL DECLARATION
Will the applicant or future building occupant handle a hazardous material
or a mixture containing a hazardous material equal to or greater than the
amount specified on the hazardous materials information guide?
Yes ❑ No ❑
Will the intended use of the building by the applicant or future building
occupant require a permit for construction or modification from the South
Coast Air Quality Management District (SCAQMD)? See permitting
checklist for guidelines.
Yes ❑ No ❑
I have read the hazardous materials information guide and the SCAQMD
permitting checklist, I understand my requirements under the Los Angeles
County Code Title 2, Chapter 220 Sections 220.100 through 220.140
concerning hazardous material reporting and for obtaining a permit from
the SCAQMD.
ASBESTOS NOTIFICATION
❑ Notification letter sent to SCAQMD or EPA
❑ 1 declare that notification of asbestos removal is not applicable to
addressed project.
CONSTRUCTION LENDING AGENCY
I hereby affirm under penalty of perjury that there is a construction lending
agency for the performance of the work for which this permit is issued
(Sec. 3097, Civ.C.).
Lender's Name
Lenders Address
Teq?
1 certify that l have read this application and state
under the penalty of perjury that the above
information is correct. l agree to comply with all City
and County ordinances and State laws relating to
building construction, and .hereby authorize
representatives of is County to enter upon the
abov entioned r 'perty for inspection rposes.
.,nom Z� v3
Owner Signature Dale
Company Name (if employed by an entity/agency) Date Applicant or Agent S nature � - / Date /