HomeMy Public PortalAbout9933 DAINES DR_Electrical__ WORKERS'COMPENSATION DECLARATION 76 6 663 G (2-80) APPLICATION FOR ELECTRICAL PERMIT*
I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY
insure, ora certificate.of Workers'Compensation Insurance,or
a certified copy thereof(Sec. 3800,Lab.C.)
p FOR APPLICANT TO FILL IN JOB � n
Policy No. Company EACH NO. FEE ADDRESS `'L t%—z.
K
ONew Residential Bldgs.&Pools
Certified copy is hereby furnished. 1 &2-Family,Sq. Ft. $ — $ LOCALITY C Cf
Multi-family Sq. Ft. — NEAREST
Certified copy is filed with the county building inspection CROSS ST
department. Residential Swimming Pools OWNER OR QQ �
FIRM NAME UZ'�I i —
Date Applicant Outlets: Rec.^Light Sw. MAIL
First 20 ADDRESS
CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. Additional CITY Tel No. 2 �'7
COMPENSATION INSURANCE }
PLAN CHECK 0-
APPLICANT
(This section need not be completed if the work involved U
Lighting Fixtures First
by the permit is for one hundred dollars ($100) or less.) Additional cc
Total No.I certify that.in the performance of the work for which this Fixed Appliances Not Over 1 HP CITY Tel No. 0
permit is issued, I shall not employ any person in any manner PERMIT l �R���.t W
so as to become subject to the Workers' Compensation Laws. Range_ Heater_D.W. APPLICANT �/`y 1i1. d
Oven _ Dryer_W.M. ADDRESS "101--1, U)
a. �N z
Date Applicant Top _ FAU )LW.H.,_ -
Hood _ Fan _Other_ CITY���� �y (Tel No. Z�j[�r3
NOTICE TO APPLICANT: If, after making this Certificate of Disp. _ Room Air Cond._X_ 3.00 `j LICENSE OR
Exemption, you should become subject to the Workers' REG. NUMBER Class
Compensation provisions of the Labor Code, you must forth- Power Apparatus& Large Appliances DISTRICT NO. PROC SED BY
with comply with such provisions or this permit shall be Size&Type HP,KW, KVA,or KVAR �^ v w
deemed revoked.' Jo
Up to 1 Incl. FINAL '
Over 1 to 10 Incl. DATE /C
LICENSED CONTRACTORS DECLARATION Over 10 to 50 Incl. [ / VALIDATION.
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 Busi- BY
( g ) Over 100 `
ness and Professions.Code, and my license is in full force and
effect. Services7�w�
0-200 Amp. Under600 V
License Number Lic.Class r6
201-1000 Amp. Under 600 V
Contractor Date Over 1000 Amp.or Over 600 V
HOME OWNER-BUILDER DECLARATION Temp. Power Pole&Appurtenances
I hereby affirm that I am 8xempt from the Contractor's Sign with One Branch Circuit
LicenseLawfor the following reason (Section 7031.5, Busi- Additional Sign Branch Circuits
i
and ofessions Code): 4 0 Q 0 A
Misc.Conduits& Conductors
I, as owner of the property, will do the work and the Other (See Complete Fee Schedule)— #;o 0 0 0 0 2
structure is not intended or offered for sale (Section
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY 2 0.0 2 Q
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is PERMIT FEE (Sub-Total) o 0 0 2 9,5 0•v
issued(Sec. 3097,Civ.C.).
Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee) .0514-82
Lender's Address PERMIT ISSUING FEE SO
I certify that -1' have read this application and state that the TOTAL FEE SQ
above information is correct. I agree to comply with all County
ordinances and State laws regulating Electrical wiring, and
he by orize representatives of this County to enter upon
t e v - entioned pr y for i pection pur oses.
_ SEE'REVERSE FOR EXPLANATORY LANGUAGE
9L
Signature of Permittee Date
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... COUNTY OF LOS ANGELES TEMPLE CITY # 0508 ELECTRICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS EL 0508 1011290007
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
LEGAL ID: I FEES PAID I BUILDING ADDRESS: I
ITR: 13805 LT: 53 9933 DAINES DR I
I [,FEE. DESCRIPTION: QUANTITY: UOM: AMOUNT: j TEMP CA 917802639 1
(ASSESSOR INFORMATION NUMBER: I I NEAREST CROSS STREET: I
18588-016-028 IA1 PERMIT ISSUANCE FEE 27.80 I THOMAS PAGE: 597 GRID: A3 LOCALITY: TEMPLE CITY, Cl
I IG1 OUTLETS-LGT,SW,RECP 18.00 OUT 34.90 I
(TENANT: IG2 LIGHTING FIXTURES 6.00 LGT 11.60 JISSUED ON: PROCESSED BY: PLAN BY: 1
1 IH2 RES GRBG DISP LT 3HP 1.00 DIS 10.90 11/29/10 SR
I IH3 RES DISHWASHR LT 3HP 1.00 DIS 10.90 1
(OWNER: TEL. NO: IH4 RES RANGE HDS LT 3HP 1.00 HOO 10.90 IFI DATE FI BY: CODE:
ICHI CHIH LIU (626) 447-8558- 1H5 RES WASH MACH LT 3HP 1.00 WAS 10.90 ��I1R
19933 DAINES DR I TOTAL FEES 117.90 rr//
ITEMP 917802639 I 1D SCRI TIO OF WORK I
ELECTRICAL FOR ADDITION AND REMODEL I
(APPLICANT: TEL. NO: I
IJIANBING YANG (626) 674-0647- 1 I
11949 FALSTONE AVE ISPECIAL CONDITIONS: I
IHACIENDA HTS 91745 I I
ICONTRACTOR: TEL. NO: j 1APPROVALS DATE INSPECTOR SIGNATURE 1
IJIANPING YANG (626) 674-0647- I 1
11949 FALSTONE AVE LIC. NO ITEMPORARY POWER POLE I I
IHACIENDA HEIGHTS, CA 91745 644420/B 1 I I I
1 (UNDERGROUND CONDUIT 1
(ARCHITECT OR ENGINEER: TEL. NO: 1 IUFER GROUND I I I
1 LIC. NO: I IROUGH CONDUIT I I I
I TROUGH WIRING
IMAIN WATER LINE I 1
I 1PLASTIC YIN METAL YIN 1 I I
I 1UTILITY COMPANY NOTIFIED( I
I I I I I I
I I I I I I
I I I I I I
(REPORT ID: DPR265 ROUTE TO: BS0508 I I I I