HomeMy Public PortalAbout4819 CAMELLIA AVE_Electrical__ WORKERS'COMPENSATION DECLARATION 76A663
CE 806G
I2-601 APPLICATION
FOR ELECTRICAL PERMIT
1 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 thereofr�(See. 3800.Lab.C.) '1
`.dLr - � r FOR APPLICANT TO FILL IN JOB Q I
Policy No Company =1s=;1,
✓5N'7 Wes.
L
TN4
ADDRESS r_ New Residential Bldgs.&Pools EACH NO. FEE 0
.� Certified copy is hereby furnished. 1 &2-Family,Sq. Ft. ' $ — $ LOCALITY C-'
OMultifamily Sq. Ft. — NEAREST
Certified copy is filed with the county building inspection CROSS ST
department. Residential Swimming Pools OWNER OR
,� ����--//yy FIRM NAME 'Sr.OTT OW-V
Date_,?-2-x2 A licant 2. Art[nm,k L/et7Y/r r�•1. "I/ #--
� L I MAIL
PD �putl ets: Rea.1, ightyt� Sw.L
•ter First 20 a ® 'x0 � ADDRESS /
CF.RT1171CATE OF EXEMPTION FROM WORKERS' Total No.4;1= Additional 3 b CITY Tel NO. J
COMPENSATION INSURANCE }
PLAN CHECK
(This section need not be completed if the work involved _ � l00 APPLICANT U
by the permit is for one hundred dollazs (5100) or less.) Lighting Fixtures First 20 ADDRESS
Total No. 4� Additional - ¢
I certify that in the'performance of the work for which this CITY Tel No.
employ an
permit is issued, 1 shall not em Fixed Appliances Not Over 1 HP I-
p y person in any manner PERMIT t � .
so as to become subject to the Workers' Compensation Laws. Range_ Heater_D.W. APPLICANT - /(5 Wrr
Oven _ Dryer_W.M._ ADDRESS .� r Z
Date Applicant Top _ FAU W.H. Qk� i f
Hood X Fan '1C Other_ CITY Tel No.;?//
NOTICE TO APPLICANT: If, after making this Certificate of Dis � DO LICENSE O
p. Room Air Cond.
Exemption, you should become'subject to the Workers' REG.NUMBER • Class -r
Compensation provisions of the Labor Code, you must forth- Power Apparatus& Large Appliances DISTRICT NO. PROCES ED BV
with comply with such provisions or this permit shall be r/
deemed revoked. Size&Type HP,KW, KVA,or KVAR G d
Up to 1 Incl.
Over 1 to 10 Incl. DA EL77 �J QQ 7
LICENSED CONTRACTORS DECLARATION VALIDATION
Over 10 to 50 Incl.
I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. FINAL
9 (commencing with Section 7000)of Division 3 of the.Rosi- BY Over 100
ness lurid Professions.Code, and my-license is in full force and
effect. pp Services
License Number33SO6 7 Lic.Class L_y 0 0-200 Amp. Under 600 V •%
�• 201-1000 Amp. Under 600 V
Contractor//a fZ"91I Date •.7-2 -71`2 Over 1000 Amp,or Over 600 V 7dp
�i ,
HOME OWNER-BUILDER DECLARATION Temp.Power Pole&Appurtenances
1 hereby affirm that 1 am exempt from the Contractor's Sign with One Branch Circuit
License Law for the following reason'(Section 70 31.5, Busi- Additional Sign Branch Circuits
ness and Professions Code):
Misc.Conduits& Conductors - 31 2 1 A
F] 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 # o�e o o e 2
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY 2'O °'6 9.9 0
1 hereby affirm that there is a construction lending agency
for the performance of the work for which this permit,is PERMIT FEE (Sub-Total) e:e 1e 6 9,9 0 5
issued (Sec. 3097,Civ.C.).
Lender's Name PLAN CHECKING FEE) -'(OneFourtti Permit Feel O 3 0 2-8 2
Lender's Address PERMIT ISSUING FEE - -
I certify that 1 have read this application and state thatthe TOTAL FEE
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 to enter upon
the above-mentioned property f inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
ignatu e•o W rmittee D '
• COUNTY OF LOS ANGELES TEMPLE CITY # 0508 ELECTRICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS EL 0508 1205110025
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
ILEGAL ID: I FEES PAID BUILDING ADDRESS:
ITR: 14467 LT: 49 1 4819 CAMELLIA AV
IEEE DESCRIPTION: QUANTITY: UOM: AMOUNT: ( TEMP CA 917804241
(ASSESSOR INFORMATION NUMBER I I NEAREST CROSS STREET:
18589-015-026 1A1 PERMIT ISSUANCE FEE 27.80 THOMAS PAGE: 597 GRID: AS LOCALITY: TEMPLE CITY CAI
I IG2 LIGHTING FIXTURES 1.00 LOT 2.00
ITENANT: I TOTAL FEES 29.80 (ISSUED ON: PROCESSED BY- PLAN BY: 1
105/11/12 SR
I I I
10WNER: TEL. NO: 1 IFINAL DATE FINAL Y: CODE: 1
I ARVISO LAWRENCE J;MARGIE M
11128 VERA CRUZ ST
IMBLO 906402551 IDESCRIPT�OF WORK 1
INSTALL LIGHTING FIXTURE (1
(APPLICANT: TEL. NO: 1 1
(TONY'S REFRIGERATION (562) 948-4194-
18815 DUNLAP CROSSING ISPECIAL CONDITIONS: I
RD PICO RIVERA 90660
CONTRACTOR: TEL. NO: JAPPROVA1,S DATE INSPECTOR SIGNATDRE
TONY'S REFRIGERATION (562) 948-4194- 1
18815 DUNLAP CROSSING LIC. NO ITEMPORARY POWER POLE I I I
IPICO RIVERA CA 90047 610858 '
UNDERGROUND CONDUIT
I
ARCHITECT OR ENGINEER: TEL. NO: JUFER GROUND
LIC. NO: ROUGH CONDUIT
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ROUGH WIRING
I � I
MAIN WATER LINE
IPLASTIC YIN METAL YIN
(UTILITY COMPANY NOTIFIEDI I
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I• ADDITIONAL DATA ON FILE
REPORT ID: DPR265 ROUTE TO: 850508
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