HomeMy Public PortalAbout4845 GOLDEN WEST AVE_Electrical__ WORKERS'CI have AcION DECLARATION CE Io/el APPLICATION FOR ELECTRICAL PERMIT
' I-hereby affirm that I have a certificate of consent to self ,
Insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING• AND SAFETY
or a certified copy thereof (Sec. , Lab. C. u
policy No: Company FOR APFUC NT TO RLL IN _013
Certified copy Is hereby famished EACH NO. Fff ADDRESS 7J C
New Residential Bldgs. & Pools
❑ Certified copy Is filed with the county building Inspec- 1 & 2-Family, Sq. Ft. $ — $ LOCALFrY fiJyJ ��
tion department. Multi-family Sq. Ft. — QST
Jr
Date ^�- Applicant Residential Swimming Pools CROSS ST.OWNER OR
NAW
CERTIFICATE OF EXEMPTION FROM KERS' �Q FIRM
MAIL
COMPENSATION INSURANCE Outlets: RecLlght�Svq,�
(This section need not be completed If the work imrolved by Total No ! ,dQ� Firit 20
the permft Is for one hundred dollars (:100)or lees.) �_ Additional Cin / - Tel. No.
I certify that In the performance of the work for which this PLAN CHECK
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
DateArpllcant CITY Tel. No.
Fixed Appliances Not Over 1 HP
NOTICE TO APPLICANT: If, after making this Certificate of PERAkr4Nr O ` s
Exemption, you should become subject to the Workers' Range— H6ater_D.W.
Compensation provislons of the Labor Code, you must forth- Oven — Dryer —W.M.— ADDRESS
with comply with such provisions or this permit shall be Top p — FAU —W.H.
deemed revoked. Hood _ Fan —Other—
CITY Tel. No.
LICENSED CONTRACTORS DECLARATION LKE14M OR
I hereby affirm that I am licensed under provisions of ChDlsp. — Room Air Cond.
Chapter 9 REG. NUMBER Class
(carand Pro r�clngenio with Section y license
of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT ,_ BY
and Professloru Code,and my license b In full force and effect. r
Size 8 Type HP, KW, KVA, or KVAR'
Lianas Number ��`� I Ic. Class _ Up to 1 Incl. FINAL
DATE
Contractor Date ( Over 1 to 10 Incl.
❑ Over 10 to 50 Incl. A
I am exemp er Sec. Over 50 to 100 Inc. B
B.BP.C. for this reason Over 100 Z
Services, Swbd., MCC& Pa noIboa rds —
Date: OI
0 -200 Amp. Under 600 V ^P
Signature 201 - 1000 Amp. Under 6010V #;9 4 2 Z 0
❑ Over 1000 Amp. or Over 600 V
Exemption for Reg. Malnt. Elect. •� 0 1{I O 11.006 O O
SINGLE FAMILY Temp. Power Pole &Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit O 3 2 1 8 6
1 hereby affirm that I am exempt from the Contractors License Additional Sign Branch Circuits
Law for the following reason (Section 7031.5, Business and
Professions Code):
❑ I, as owner of the property, will do the work and the Mlsc. Conduits 8 Conductor
structure Is not Intended or offered for sale (Section Other (See Complete Fee Schedule)_ ,
7044, Business and Profeuions 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)
(Sec. 3097, Civ. C.).
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE
Lender's Address O!
I certify that I have reod this application and state that the TOTAL FEE f
above Informatlon Is correct. I agree to comply with all County
ordinances and Stat laws regulating Electrical wiring, and
hereby orize re tatives of this County to enter upon
the ab mention for Inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE .
Slgna re of er Itt Date
-`� COUNTY OF LOS ANGELES TEMPLE CITY * 0508 P7MiT
DEPARTMENT OF PUBLIC WORKS 9071 LAS TUNAS EC 050$9810090002
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (818) 285-0488 EXT:
LEGAL ID: FEES PAID BUILDINO-ADDRESS:
TR: 5342 LT: 6 -,4845--GQ(-DEN WEST AV
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917803936
ASSESSOR INFORMATION NUMlBER: NEAREST CROSS STREET: LOWER AZUSA
8589-019-007 Al PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 597 GRID: A5 LOCALITY: TEMPLE CITY
G1 OUTLETS-LGT,SW RECP 7.00 OUT 13.65
G2 LIGHTING FIXT5kES 2.00 LGT 3.90 .
TOTAL FEES 45.30 10/09/98 UT 10/09/99
OWNER: TEL. NO: FINAL DATE FILLAL BY:
CHENG•PETER (626) 292-2868- (�
4847 G)LDEN WEST AV � .
)
TEMP 917803936 - - J
EOECTRICAL -FQR-THIRD-BEDROOM-IN EXISTING
SQ. FT.
APPLICANT: TEL. NO:
SAME AS OWNER -
SPECIAL ITIONS:
5 PTAiSE I E S COCONTRACTOR: TEL. NO: CA
APPROVALS DATE INSPECTOR SIGNATURE
SAME AS OWNER - `� �Ty
LIC. MO TEMPORARY POWER POLE
UNDERGROUND CONDUIT
ARCHITECT OR ENGINEER: TEL. NO: UFER GROUND
LIC. NO: 111111ROUGH CONDUIT
MAIN WATM-LINE
IP u 1 L (D w O K S PLASTIC Y/N METAL Y/N
UTILITY COMPANY NOTIFIED
ervic0 Th
REPORT ID: DPR265 ROUTE TO: RS0508