HomeMy Public PortalAbout10750 GRAND AVE_Electrical_10/20/2014_" C O U N T Y O F L O S A N G E L E S
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( U T I L I T Y C O M P A N Y N O T I F I E D (
- A D D I T I O N A L D A T A O N F I L E
R E P O R T I D : D P R 2 6 5 R O U T E T O : B S O S 0 8
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from
the Contractors' State License Law for the reason(s) indicated
below by the checkmark(s) I have placed next to the applicable
item(s) (Section 7031.5, Business and Professions Code): Any
city or county that requires a permit to construct, alter, improve,
demolish, or repair any structure, prior to its issuance, also
requires the applicant for the permit to file a signed statement
that he or she is licensed pursuant to the provisions of the
Contractors' State. License Law (Chapter 9 (commencing with
Section 7000) of Division 3 of the Business and Professions
Code)' or that he or she is exempt from licensure 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).):
U I, as owner of the property, or my employees with wages as
their sole compensation, will do (J) all of or U portions of the
work, and the structure is not intended or offered for sale
(Section 7044, Business and Professions Code: The
Contractors' State License Law does not apply to an owner of
property who, through employees' or personal effort, builds or
improves the property, provided that the 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 it was not built or
improved for the purpose of sale.).
U I, as owner of the property, am exclusively contracting with
licensed Contractors to construct the project (Section 7044,
Business and Professions Code: The Contractors' State License
Law does not apply to an owner of property who builds or
improves thereon, and who contracts for the projects with a
licensed Contractor pursuant.to the Contractors' State License
Law).
(_) I am exemdt from licensure under the Contractors' State
License Law for the following reason:
By my signature below I acknowledge that, except for my
personal residence in which I must have resided for at least
one year pdorl to completion of the improvements covered by
this permit, I cannot legally sell a structure that 1 have built as an
owner -builder If it has not been constructed in its entirety by
licensed contractors. I understand that a copy of the applicable
law, Section 7044 of the Business and Professions Code, is
available upon request when this application is submitted or at
the following Web site: httD://www.leoinfo.m.ciov/calaw.html.
Date:
Signature of Property Owner or Authorized Agent
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 fullforce d effect.
License Class License No. t� _ S� 3
114'4 � ContraSignature
ofor _
WORKERS' COMPENSATIN DECLARATION
WARNING: FAILURE TO SECURE WORKERS' 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.
I hereby affirm under penalty of perjury one of the following
declarations:
I have and will maintain a certificate of consent to self -
insure for workers' compensation, issued by the Director of
Industrial Relations as provided for by Section 3700 of the
Labor Code, for the performance of the work for which this permit
is issued.
Policy No.
I have and will maintain workers' compensation
insurance, as required by Section 3700 of the Labor Code, for
the performance of the work for which this permit is issued. My
A kers' oompensatio insurance carrier and policy number are:
/-/r'f t'(A�Y�_fN( J 11'�.S
amer o is umbel. 'Expiration Date
Name of Agent Phone Number
I 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 workers' compensation laws of
California, and agree that, if I should become subject to the
workers' compensation provisions of Section 3700 of the Labor
Code shall forthwith comply w those provisions
/ Signature of Applicant Date
v
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 at seq.,
(relating to the Los Angeles County Lobbyist Ordinance) and that
all persons acting on behalf of myself complied and will continue
to corn ly therewith through the application process.
Aplicant (Print Name) Applicant Signature
Company Name Date
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 ❑ N o ❑
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 AQMD and/or EPA
❑ I declare that notification of asbestos removal is not
applicable to addressed project.
DECLARATION REGARDING 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 (Section 3097, Civil Code).
Lender's Name
Lender's Address
By my signature below, I certify to each of the following:
I am the property owner or authorized to act on the
property owner's behalf.
I have read this application and the information I have
provided is correct.
I agree to comply with all applicable city and county
ordinances and state laws relating to building
construction.
I authorize representatives of this county to enter the
above -identified property for inspection purposes.
Signature of operty Owner or Autorized Agent
Date
C"
COUNTY bF LOS ANGELES
DEPARTMENT OF PUBLIC WORKS
BUILDING AND SAFETY / LAND DEVELOPMENT
LEGAL ID:
ITR: 4902 LT: 1 BE: E
ASSESSOR INFORMATION NUMBER:
18574-024-001
IXIAO YAN, WEN
10750 GRAND AV
TEMP 917803544
APPLICANT:
ISAME AS OWNER
CONTRACTOR:
SAME AS OWNER
ARCHITECT OR ENGINEER:
LIU, TIENKUANG
9698 TELSTAR AVENUE #308
EL MONTE CA 91731
TEL. NO:
(626) 988 -3678 -
TEL. NO:
TEL. NO:
LIC. NO
TEL. NO:
(626) 348 -7137 -
LIC. NO:
NONE
TEMPLE CITY # 0508
9701 LAS TUNAS
TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
FEES PAID
FEE DESCRIPTION: QUANTITY: UOM:
Al PERMIT ISSUANCE FEE
G1 OUTLETS-LGT,SW,RECP 20.00 OUT
G2 LIGHTING FIXTURES 9.00 LOT
HA FAU LESS 3HP 2.00 FAU
JB AC UNITS +3-10HP 2.00 AC
TOTAL FEES
ID: DPR265
ROUTE TO: SS0508
ELECTRICAL PERMIT
EL 0508 1408250088
BUILDING ADDRESS:
10750 GRAND AV
AMOUNT;j TEMP CA 917803544
NEAREST CROSS STREET: PERSIMMON
27.80 THOMAS PAGE: 597 GRID: D4 LOCALITY: TEMPLE CITY
40.00
18.00 JISSURD ON: PROCESSED BY: PLAN BY:
22.00 08/25/14 SR
39.40 1
147.20F NAA/,,yL DD"A, T� F BY: CODE:
RC IPTTIION OF WORK
120 OUTLETS, 9 LIGHT FIXTURES AND 2 A/C + FAU UNITS
CONDITIONS:
APPROVALS DATE
TEMPORARY POWER POLE
UNDERGROUND CONDUIT
UFER GROUND
ROUGH CONDUIT ({{
ROUGH WIRING %•/��*
MAIN WATER LINE `II1
PLASTIC YIN METAL YIN
UTILITY COMPANY NOTIFIED
INSPECTOR SIGNATURE
�J�
OWNER -BUILDER DECLARATION LICENSED CONTRACTOR'S DECLARATION JOB ADDRESS
I hereby affirm under penalty of perjury that I am exempt from
the Contractors' State License Law for the reason(s) indicated
below by the checkmark(s) I have placed next to the applicable
item(s) (Section 7031.5, Business and Professions Code): Any
city or county that requires a permit to construct, alter, improve,
demolish, or repair any structure, prior to its issuance, also
requires the applicant for the permit to file a signed statement
that he or she is licensed pursuant to the provisions of the
Contractors' State License Law (Chapter 9 (commencing with
Section 7000) of Division 3 of the Business and Professions
Code) or that he or she is exempt from licensure 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).):
U I, as owner of the property, or my employees with wages as
their sole compensation, will do (,/} all of or U portions of the
work, and the structure is not intended or offered for sale
(Section 7044, Business and Professions Code: The
Contractors' State License Law does not apply to an owner of
property who, through employees' or personal effort, builds or
improves the property, provided that the 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 it was not built or
improved for the purpose of sale.).
(_) I, as owner of the property, am exclusively contracting with
licensed Contractors to construct the project (Section 7044,
Business and Professions Code: The Contractors' State License
Law does not apply to an owner of property who builds or
improves thereon, and who contracts for the projects with a
licensed Contra ?tor pursuant .to the Contractors' State License
Law).
I am exempt from licensure under the Contractors' State
License Law for the following reason:
By my signature below I acknowledge that, except for my
personal residence in whicq I must have resided for at least
one year prion to completion, of the improvements covered by
this permit, I c�'nnot legally sell a structure that 1 have built as an
owner -builder if it has not been constructed in its entirety by
licensed contractors. I understand that a copy of the applicable
law, Section 7044 of 'the Business and Professions Code, is
available upon request when this application is submitted or at
the following Web site: httD://www.leoinfo.ca'.aov/calaw.html.
Date: � l Z,7 ` ,
Signature of Property Owner or Authorized Agent
Q��
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 Class License No.
Date Contractor Signature
WORKERS' COMPENSATION DECLARATION
WARNING: FAILURE TO SECURE WORKERS' 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.
I hereby affirm under penalty of perjury one of the following
declarations:
I have and will maintain a certificate of consent to self -
insure for workers' compensation, issued by the Director of
Industrial Relations as provided for by Section 3700 of the
Labor Code, for the performance of the work for which this permit
is issued.
Policy No.
I have and will maintain workers' compensation
insurance, as required by Section 3700 of the Labor Code, for
the performance of the work for which this permit is issued. My
workers' compensation insurance carrier and policy number are:
Carrier Policy Number Expiration Date
Name of Agent Phone Number
_ I 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 workers' compensation laws of
California, and agree that, if I should become subject to the
workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions
4.0
Signature of A�p�licant Date
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
Company Name Date
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 ❑ Ro ❑
i
I have read the hazardous materials information guide and the
SCAQMD permitting checklist, I understand my requirem nts
under the Los Angeles County Code Title 2, Chapter 20'
Sections 220.100 through 220.140 concerning hazardous
material reporting and for obtaining a permit from the SCAQMD.
ASBESTOS NOTIFICATION
❑ Notification letter sent to AQMD and/or EPA
❑ I declare that notification of asbestos removal is not
applicable to addressed project.
DECLARATION REGARDING 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 (Section 3097, Civil Code).
Lender's Name
Lender's Address
By my signature below, I certify to;each of the following:
I am the property owner or authorized to act on the
property owner's behalf.
I have read this application and the information I have
provided is correct.
I agree to comply with all applicable city and county
ordinances and state laws relating to building
construction.
I authorize representatives of this county to enter the
above -identified property for inspection purposes.
Signature of Property Owner or Authorized Agent
Date
COUNTY'Or LOS ANGELES
DEPARTMENT OF PUBLIC WORKS
BUILDING AND SAFETY / LAND DEVELOPMENT
LEGAL ID:
IN: 4902 LT: 1 BL: E
4SSESSOR INFORMATION NUMBER:
8574-024-001
iwSl oY
TEL. NO:
YAN, WEN (626) 988 -3678 -
GRAND AV
917803544
SCANT: TEL. NO:
ALLEN Y (626) 284-3260-
W GARVEY AVE
'EREY PARK 91754
INTRACTOR: TEL. NO:
M P B CONSTRUCTION INC. (626) 284-3260-
3 W GARVEY AVENUE B834 LIC. NO
INTEREY PARK CA 91754 863573
CHITECT OR ENGINEER: TEL. NO:
LIC. NO
TEMPLE CITY # 0508
9701 LAS TUNAS
TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
FEES PAID
DESCRIPTION: QUANTITY: UOM:
PERMIT ISSUANCE FEE
120V, 15/20A BR CKTS 16.00 BR
OUTLETS-LGT,SW,RECP 18.00 OUT
LIGHTING FIXTURES 18.00 WT
200 AMP PANELS, MCC 1.00 PAN
TOTAL FEES
ADDITIONAL DATA ON FILE
REPORT ID: DPR265 ROUTE TO: BS0508
ELECTRICAL PERMIT
EL 0508 1502110018
BUILDING ADDRESS:
10750 GRAND AV
AMOUNT: TEMP CA 917803544
NEAREST CROSS STREET: PERSIMMON
27.80 I THOMAS PAGE: 597 GRID: 04 LOCALITY: TEMPLE CITY CA
260.30
36.00 ISSUED ON: PROCESSED BY: PLAN BY:
36.00 02/11/15 SR
38.90
399.00 IF DfAT&' FINIyL y�Y: CODE:
11 'Fyl'I<i{`(D/N OF WORK—/Uf`n/v/
IRE -WIRE EXISTING HOUSE AND UPGRADE SERVICE PANEL TO 200 AMP
CONDITIONS:
MALS DATE
iRARY POWER POLE
GROUND CONDUIT
GROUND
CONDUIT
WIRING
WATER LINE
'IC YIN METAL YIN
TY COMPANY NOTIFIED
INSPECTOR SIGNATURE
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from
the Contractors' State License Law for the reason(s) indicated
below by the checkmark(s) I have placed next to the applicable
item(s) (Section 7031.5, Business and Professions Code): Any
city or county that requires a permit to construct, alter, improve,
demolish, or repair any structure, prior to its issuance, also
requires the applicant for the permit to file a signed statement
that he or she is licensed pursuant to the provisions of the
Contractors' State License Law (Chapter 9 (commencing with
Section 7000) of Division 3 of the Business and Professions
Code) or that he or she is exempt from licensure and the basis
for the alleged exemption. Any violation of Section 7031.5 by
any applicant for a permit subject the applicant to a civil
penalty of not more than five hundred dollars ($500).):
U I, as owner of the property, or my employees with wages as
their sole compensation, will do (✓) all of or (_) portions of the
work, and the structure is not intended or offered for sale
(Section 7044, Business and Professions Code: The
Contractors' State License Law does not apply to an owner of
property who, through employees' or personal effort, builds or
improves the property, provided that the 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 it was not built or
improved for the purpose of sale.).
U I, as owner of the property, am exclusively contracting with
licensed Contractors to construct the project (Section 7044,
Business and Professions Code: The Contractors' State License
Law does not apply to an owner of property who builds or
improves thereon, and who contracts for the projects with a
licensed Contrbctor pursuant.to the Contractors' State License
Law).
(-). I am exem{ t from licensure under the Contractors' State
License Law for the following reason:
By my signature below I acknowledge that, except for my
personal residence in which I must have resided for at least
one year priorl to completion of the improvements covered by
this permit, I cannot legally sell a structure that I have built as an
owner -builder if it has not been constructed in its entirety by
licensed contractors. I understand that a copy of the applicable
law, Section 7044 of the Business and Professions Code, is
available upon request when this application is submitted or at
the following Web site: httD://www.leainfo.ra.aovlcalaw.html.
Date:
Signature of Property Owner or Authorized Agent
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. G� 7
- �ticense Class IryLicense No.
-
Date Contractor Signature 'Te -
WORKERS' COMPENSATION DECLARATION
WARNING: FAILURE TO SECURE WORKERS' 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.
I hereby affirm under penalty of perjury one of the following
declarations:
I have and will maintain a certificate of consent to self -
insure for workers' compensation, issued by the Director of
Industrial Relations as provided for by Section 3700 of the
Labor Code, for the performance of the work for which this permit
is issued.
2olicy No.
I have and will maintain workers' compensation
insurance, as required by Section 3700 of the Labor Code, for
the performance of the work for which this permit is issued. My
w <ers' compensatio insurance carrier nd olicy number are:
Came Policy Number Dat
Name of Agent Phone Number
I certify that, in the performance of the work for which this
permit is issued, 1 shall not employ any person in any manner
so as to become subject to the workers' compensation laws of
California, and agree that, if I should become subject to the
workers' compensation provisions of Section 3700 of the Labor
Code, I shall rthwith comply with those provisions
Signature of Applicant Date
LOBBYIST ORDINANCE CERTIFICATION
Complete this section for permit 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 at 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
Company Name Date
JOB ADDRESS
LOCALITY
HAZARDOUS MATERIAL DECLARATION
Will the applicant or future building occupant handle a hazardous
material or a mixture confining 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 ❑ 1
I have read the hazardous matedals information guide and the
SCAQMD permitting checklist, I understand my req uirem
gnIs
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 AQMD and/or EPA
❑ I declare that notification of asbestos removal is not
applicable to addressed project.
DECLARATION REGARDING 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 (Section 3097, Civil Code).
Lender's Name
Lenders Address
By my signature below, I certify to'each of the following:
I am the property owner or authorized to act on the
property owner's behalf.
I have read this application and the information I have
provided is correct.
I agree to comply with all applicable city and county
ordinances and state laws relating to building
construction.
I authorize representatives of this county to enter the
above -identified property for inspection purposes.
Signature f Property Owner or Authorized Agent