HomeMy Public PortalAbout9035 EMPEROR AVE_Electrical__ WORKERS' COMPENSATION cafeDECLARATION CE-806 10/61 APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self CE-806G
insure, or a certificate of Workers' Compensation Insuran e, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or certif' d copy thereof (Sec. 380 Lab. /
Po"lic�o0_36 Campo �� r t p FOR APPLICANT TO FILL IN JOB
91D-3
Certified copy is hereby furnished. New Residential Bldgs. 8 Pools EACH NO. FEE ADDRESS
1 & 2-Family, S Ft. $ — $ LOCALITY
Certified copy is filed with the county building inspec- Y- q•
tion epariment. Multi-family Sq. Ft. — 'NEAREST
djr Residential Swimming Pools CROSS ST.
Date Applicant OWNER OR
FIRM NAME
CERT KATE OF EXEMPTIO OM WORKERS' Outlets: Rec Light Sw._ MAIL
COMPENSATION I URANCE ADDRESS
First 20
(This section need not be completed if the work involved by Total No. CITY Tel. No ,_ -"
the permit is for one hundred dollars ($100)or less.) Additional 'L.4j
CK 67
1 certifythat in the performance of the work for which this PLAN CH
P APPLICANT
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS
Total No. Additional
CITY Tel. No.
Date Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT
Exemption, you should become subject to the Workers' Range_ Heater—D.W.
Compensation provisions of the Labor Code, you must forth- Oven Dr W.M.— ADDRESS b
with comply with such provisions or this permit shall be
deemed revoked. Hood _ Fan _ Other_ CITY I Tel. No.
LICENSED CONTRACTORS DECLARATION LICENS OR
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. REG. NUMBER [.j Class.
(commencing with Section 7000) of Division 3 of the Business DISTRICT NO. PROCESS BY
and Professions Code,and my license is in full force and effect. Power Apparatus& Large Appliances — 0
� Size &Type HP, KW, KVA, or KVAR' � sG
License Number-7 Lic. Class Upjqpl4FINAL 4�
DATE
Contract ate 1 -1 - - if
( � VALIDATION 0
IDV Over 10 to 50 Incl.
FINAL
I am empt under Se Over 50 to 100 Inc. BY @.
B.&P.C. for this reason Over 100 4A
Date: erviceswbd. MCC & Panelboards
,�. Under 600 V
Signature 201 1006 Amp. Under 600 V
❑ Exemption for Reg. Maint. Elect. Over 1000 Amp. or Over 600 V
SINGLE FAMILY Temp. Power Pole &Appurtenances 2 1.8 7 A
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit l o 0 0-o o 2
I hereby affirm that I am exempt from the Contractor's License Additional Sin Branch Circuits : • . I •
Sign u
Law for the following reason (Section 7031.5, Business and ( o•0 3:5 5 0
Professions Code):
❑ I, as owner of the property, will do the work and the Misc. Conduits&Conductors o 0 0 3 5,5 0
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)-
7044, Business and Professions Code). ® O 5 2 4'—'8 3
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)
(Sec. 3097, Civ. C.).
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE AP
Lender's Address
I certify that I have read this application and state that the 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 v
the ab entioned prooghYfor inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signatu of P rmittee ' D
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 ELECTRICAL PERMIT
•
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS EL 0508 1112210043
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
(LEGAL ID: I FEES PAID 1 BUILDING ADDRESS: 1
9035 EMPEROR AV 1
ON FILE IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT:( SGAB CA 917752016 1
(ASSESSOR INFORMATION NUMBER: I I NEAREST CROSS STREET: I
15382-011-010 IA1 PERMIT ISSUANCE FEE 27.80 1 THOMAS PAGE: 596 GRID: H1 LOCALITY: TEMPLE CITY, Cl
I IG1 OUTLETS-LGT,SW,RECP 2.00 OUT 3.90 1 1
(TENANT: IG2 LIGHTING FIXTURES 1.00 LGT 1.90 (ISSUED ON: PROCESSED BY: PLAN BY:
TOTAL FEES 33.60 112/21/11 SR 1
(OWNER: TEL. NO: 1- (FINAL DATE FI BY: CODE: 1
ICHANG CHIAO CHANG;GUH SHU HUEY (626) 451-0931- I 1
19035 EMPEROR AV I
ISGAB 917752016 1 IDISCRIPTION OF WORK 1
IGFI OUTLET AT KITCHEN AND GARAGE NEW SECURITY LIGHT AT GARAGI
I IE (EXTERIOR)
(APPLICANT: TEL. NO: 1 I I
ICERVANTES, LEONARD (818) 854-1159- I I I
122035 BURBANK BLVD. I (SPECIAL CONDITIONS: 1
(WOODLAND HILLS 91367 1 I I1
DAM-
(CONTRACTOR: TEL. NO: 1 (APPROVALS DATE INSPECTOR SIGNATURE 1
1ARBEL CONSTRUCTION INC. (800) 787-8909- I 1 1
122025 VENTURA BLVD. #205 LIC. NO I (TEMPORARY POWER POLE I I
IWOODLAND HILLS, CA 91364 894807 1 1 I
1 (UNDERGROUND CONDUIT
1ARCHITECT OR ENGINEER: TEL. NO: 1 IUFER GROUND I
1 LIC. NO: 1 (ROUGH CONDUIT 1 1 1
I I IROUGH WIRING 1 1 I
I 1 IMAIN WATER LINE I I I
I 1 (PLASTIC YIN METAL YIN I I
1 1 (UTILITY COMPANY NOTIFIED( I I
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(REPORT ID: DPR265 ROUTE TO: BS0508 I I
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