HomeMy Public PortalAbout10817 FREER ST_Electrical__ WORKERS' COMPENSATION DECLARATION 2o-ooieDPW aie7 APPLICATION FOR ELECTRICAL PERMIT O
I hereby affirm that I have a certificate of consent to self CE_806 cE-eoaG
insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
or a certified copy jhpreof (Sec. 3800,, Lab.
C.)
Policy No. . ompany, 1C.C/ jegLD FOR APPLICANT TO FILL IN JOB
❑Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADDRESS !✓`
Certified copy is filed with the county building inspec- 1 &'2-Family, Sq. Ft.; $ — $ ` LOCALITY
lion de artment. Multi-family Sq. Ft. NEAREST n ) �� S
CROSS ST. 4 / 6
f /�` /f�OL'J � /��l Residential Swimming Pools OWNER OR
Date Applicant 1+�e!"� FIRM NAME 16 onYt/ ,
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw._ MAIL /+
COMPENSATION INSURANCE ADDRESS j, l 6
First 20
(This section need not be completed if the work involved by Total No. Additional CIT`; '4 Tel. No.
the permit is for one hundred dollars ($100)or less.) PLAN CHECK
I certify that in the performance of the work for which this 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
Additional
Total No. CITY Tel. No.
Date Applicant Fixed Appliances Not Over 1 HP PERMIT �y�
NOTICE TO APPLICANT: If, after making this Certificate of , APPLICATION ' C�tJ C
Exemption, you should become subject to the Workers' Range_ Heater—D.W.
Compensation provisions of the Labor Code, you must forth- Oven Dryer W.M.— ADDRESS-
with comply with such provisions or this permit shall be Top FAU i—W.H. —
deemed revoked. Hood — Fan —Other— CITY Tel. No
LICENSED CONTRACTORS DECLARATION Disp. LICENSE OR T
I hereby affirm that I am licensed under provisions of Chapter 9 -� Room Air Cond. REG. NUMBER Class. V
(commencing with Section 7000)of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO. PR E SED BY >-
and Professions Code,and my license is in full force and effect. CL
Size &Type HP, KW, KVA, or KVAR
License Numb A� Lic. Class Up to 1 Incl. FINALncl. DATE V
Contractor; S �, �� °�s/dDate Over 1 to 10 I _ -t VALIDATION 0
F-1 Over 10 to 50 Incl. FINAL (J I-_
I am exempt under Sec. Over 50 to 100 Inc. BY C)
B.&P.C. for this reason Over 100 a
Services, Swbd., MCC& Ponelboards ZZ
Date: 0-200 Amp. Under 600 V —
Signature 201 - 1000 Amp. Under 600 V
❑ Over 1000 Amp. or Over 600 V
Exemption for Reg. Maint. Elect.
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Temp. Power Pole &Appurtenances _
I hereby affirm that I am exempt from the Contractor's License Sign with One Branch Circuit ;,..r.•E•n Branch Circuits g
4""
Law for the following reason (Section 7031.5, Business and Additional Sign
Professions Code):
Misc. Conduits&Conductors _
Ell, as owner of the property, will do the work and the i a!E.#1=
structure is not intended or offered for sale(Section 7044, Other (See Complete Fee Schedule)_ o s
Business and Professions Code). ® T I_;I rid. .- `� e _.�5
E
CONSTRUCTION LENDING AGENCY ;,:t l ( i' y-3E
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) ;..t'ANGE °U-`
(Sec. 3097, Civ. C.).
PLAN CHECKING FEE
Lender's Name _r/C
PERMIT ISSUING FEE
Lender's Address 72 4 '
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
Above-mentioned property for inspection urp ses. SEE REVERSE FOR EXPLANATORY LANGUAGE
IV_ r /
i natur Permitte Date
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 ELECTRICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS EL 0508 1104200003
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
LEGAL ID: I FEES PAID I BUILDING ADDRESS: 1
ITR: 47219 LT: 1 UN: 6 1 1 10817 FREER ST
IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT: ( TEMP CA 917803538
(ASSESSOR INFORMATION NUMBER: I I NEAREST CROSS STREET: SANTA ANITA
18573-014-068 IA1 PERMIT ISSUANCE FEE 27.80 1 THOMAS PAGE: 597 GRID: D4 LOCALITY: TEMPLE CITY, Cl
I IG1 OUTLETS-LGT,SW,RECP 3.00 OUT 5.80 I
(TENANT: I TOTAL FEES 33.60 (ISSUED ON: PROCESSED BY: PLAN BY:
1 1 104/20/11 SR
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1OWNER: TEL. NO: I 1F AL DATE FIN BY: CODE:
LIN, THOMAS I IJ/�
10817 FREER ST
(TEMP 917803538 I (DESCRIPTION OF WORK
I (ELECTRICAL FOR KITCHEN REMODEL
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(APPLICANT: TEL. NO: I I
1168 CONSTRUCTION & REMODELING (626) 284-6682- 1 1 i
1821 S. 4TH ST. #17 1 (SPECIAL CONDITIONS: 1
IALHAMBRA, CA 91801 1 1 I
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(CONTRACTOR: TEL. NO: I (APPROVALS DATE INSPECTOR SIGNATURE I
1168 CONSTRUCTION AND REMODELING (626) 284-6682- 1 I I
1821 S. 4TH STREET #17 LIC. NO I ITEMPORARY POWER POLE I I I
IALHAMBRA, CA 91801 899733 B I I 11 I
I I (UNDERGROUND CONDUIT I I I
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(ARCHITECT OR ENGINEER: TEL. NO: I IUFER GROUND I I I
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I (REPORT ID: DPR265 ROUTE TO: BSO508 I I I
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