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WORKERS'COMPENSATION DECLARATION CE-806 10/81 n nnn C n IWN FOR E IZCTPUC �nl p fo7j'�(7(1/��l^r
' I hereby affirm that 1 have a certificate of consent to self, CE-806G /�11T ll—LU, !�1 11V FOR LSL�IS ll ll� G�1L� l�LSl1�I1V11 'll
insure, or'a certificate of Workers'Compensation Insurance,. COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified copy thereof (Sec. 3800, Lab.C.)
Policy No. Company FOR APPLICANT TO FILL IN JOB " .
❑ Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADDRESS . 4
❑ 1 & 2-Famil S Ft. $ _ $ LOCALITY
Certified copy is filed with the county building inspec, Y- q '
tion department. _ Multi-family Sq. Ft. NEAREST
CROSS ST.
Residential Swimming Pools OWNER OR V g r
Date Applicant . FIRM NAME
CERTIFICATE OF EXEMPTION FROM'WORKERS' � :MAIL
COMPENSATION INSURANCE " Outlets: Rec Light Sw. ADDRESS
s section need not be com leted if the work involved by
First 20
(Thitin
p Total Na.. CITY Tel. No.
the permit is for one hundred dollars($100)or less.) Additional
PLAN CHECK
I certify that in the performance of the work for which this APPLICANT
permit is issued, I shall hot employ any person in any(anner
so as to become subject to the Workers''eqmpensation L s. Lighting Fixtures First 20 ADDRESS
Additional
F Total No. CITY Tel. No.
Date Applicant yj3 • ''
Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: It, afteaking,this Certificate .of APPLICANT
Exemption, you should becom ' subject to the Workers' Range_ Heater—D.W.
Compensation provisions of the Labor Code, you must forth- Oven —.Dryer W.M.— ADDRESS i
with comply with such provisions or this permit shall be Top FAU —W.H. —
deemed revoked. Hood Fan _ Other— CITY j- Tel. No, �
LICENSED CONTRACTORS.DECLARATION 'LICENSE OR
I hereby off irm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. REG. NUMBER G`_,� 0 Class.
(commencing with Section 7000) of Division 3 of the Business DISTRICT NO. P C SED BY
and Professions Code,and my license is in full force and d effect. Power Apparatus 8 Large Appliances
Size &Type HP, KW, KVA, or KVAR �✓ G1'.1 / 0
License Number g +' � 4� Lic. Class Up to 1 Incl. FINAL
� Ltd Date 09
Over 1 to.10 Incl. DATE �` VALIDATIOPI O
Contractor- °'�- Over 10 to 50 Incl.
❑ FI U, =
I am exempt under Sec. Over 50 to 100 Inc, BLu"
B.&P.C. for this reason
41L_
Over 100
Date: SerJices, Swbd., MCC& Panelboards, .— o
0 - 200 Amp. Under 600'V
Signature 201 - 1000 Amp. Under 600 V z 6 2 9"8 A
Over 1000 Amp. or Over 600 V
❑_ Exemption for Reg. Maint. Elect. # 0 0 0 0 0 2
SINGLE FAMILY Temp. Power Pole &Appurtenances ® o26,25
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit ="
I hereby affirm that I am exempt from the Contractor's License o 0 0 2 6 2 5 u'
Law for the.following reason (Section 7031.5, Business and Additional Sign Branch Circuits
Professions Code): 0 1.07-87
` ❑ I, as owner of the property,•will do the work and the Misc. Conduits & Conductors ,
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ Dom/
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY .
I hereby affirm that there•'is a construction lending agency for
the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) 1
(Sec. 3097, Civ. C.).
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE
Lender's Address
I certify that I have read ,this application and state that the \OTAL FEE .
above information is correct. I agree to comply with all County
ordinances and State laws regulating Electrical wiring, and
hereby autho 'ze representatives f this County to enter upon
the above- en Toned property or inspection purposes:
SEE REVERSE FOR EXPLANATORY LANGUAGE
Si Lure of Permittee Date
.. a
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 ELECTRICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS - ,. . EL 0508 0608070011
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 -
PHONE:. (626) 285-0488 EXT:
LEGAL ID: - FEES .PAID - BUILDING ADDRESS:
TR: 12998 LT: 80 4527 ELLIS IN
FEE DESCRIPTION: - QUANTITY: UOM: AMOUNT: TEMP CA 917804251
ASSESSOR INFORMATION.NUMBER: NEAREST CROSS STREET: TEMPLE CITY
8592-001-009 Al PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 597 GRID: A5 LOCALITY: TEMPLE CITY, C
G1 OUTLETS-LGT,SW,RECP 1.00 OUT 1.95
TENANT: TOTAL FEES 29.70 ISSUED ON: PROCESSED BY: PLAN BY: EXPIRES ON:
08/07/06 JK 02/03/07
OWNER: TEL. NO: FINAL DATE FINAL BY: CODE:
SIEN PANG (626) 280-2058- .
4525 ELLIS IN - -
TEMP 917804207 DESCRIPTION OF WORK
ADD .1 OUTLET
APPLICANT: TEL. NO: '
BRETMAN YIFET (818) 987-7277-
5461 YARMOUTH AVE SPECIAL CONDITIONS:
ENCINO, CA 91316
CONTRACTOR: - TEL. NO: APPROVALS DATE ' INSPECTOR SIGNATURE
ROYALTY REMODELING, INC. (.818) 883-5588-
6269 VARIEL AVE LIC. NO TEMPORARY POWER POLE
SUITE #F 794466E
WOODLAND HILLS CA 91367 UNDE:2GROUND 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 -
REPORT ID: DPR265 ROUTE TO: BSO508