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HomeMy Public PortalAbout10307 KEY WEST ST_Electrical__ WORKERS' COMPENSATION DECLARATION 10181 APPLICATION FOR ELECTRICAL PERMIT I herelaCE-806G affirm that I have a certificate of consent to self CE-806G 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 O '.1 ✓ Certified co is hereby furnished. EACH NO. FEE ADDRESS ,o j©� PY Y New Residential Bldgs. 8 Pools 1 & 2-Family, S FL dDUU LOCALITY Pjrl'1 Certified copy is filed with the county building inspec- Y, q 7 $ — $ tion depot ent. Multi-family Sq. Ft. — NEAREST CROSS ST. `L Date to1-,F-:?L S7 Applicant �r �A �L£GT' Residential Swimming Pools OWNER OR GO FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw._ MAIL COMPENSATION INSURANCE ADDRESS � First`20d \� 1 (This section need not be completed if the work involved by Total No. Additional CITY 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 Total No. Additional CITY Tel. No. Date Applicant ' NOTICE TO APPLICANT: If, after making this Certificate of Fixed Appliances Not Over 1 HP PERMIT APPLICANT eGAOA gGi'"CTCn� G 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 I-LZS � J rtdti.. with comply with.such provisions or this permit shall be Top _ FAU _W.H. — deemed revoked. Hood CITY �cA QtA Tel. No.AJq"j 5 7 5%1. LICENSED CONTRACTORS DECLARATION _ Fon _ Other_ LICENSE OR Disp. _ Room Air Cond. Class. I hereby affirm that I am licensed under provisions of Chapter 9 REG. NUMBER 2 � &p (commencing with Section 7000) of Division 3 of the Business DISTRICT NO. PROCESY a_ and Professions Code, and my license is in full force and effect. Power Apparatus 8 Large Appliances O Size & Type HP, KW, KVA, or KVAR 1— U License Number 32`��� Lic. Class Up to 1 Incl. FINAL L(� �' t 23 �cJ Over 1 to 10 Incl. DATE ✓ '� VALIYATION Contractor "```' 'Date Over 10 to 50 Incl. ❑ FINA,1 7W I am exempt under Sec. Over 50 to 100 Inc. BY B.&P.C. for this reason Over 100 z Date: Services, Swbd., MCC& Ponelboards 0 - 200 Amp. Under 600 V Signature 201 - 1000 Amp. Under 600 V ❑ Exemption for Reg. Maint. Elect. Over 1000 Amp. or Over 600 V SINGLE FAMILY Tem Power Pole& Appurtenances pircuit ances 3 2 7.8 A HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit I hereby affirm that I am exempt from the Contractor's License Additional Sign Branch Circuits # 0 0 0 0 0 'L Law for the following reason (Section 7031.5, Business and Professions Code): J o o 9 Q 5 0 ❑ 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)_ 0 0 0 9 Q 5 0 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY Q 2 4 =8 5 1 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.). SO PLAN CHECKING FEE Lender's Name PERMIT ISSUING FEE 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 here y authorize representatives of this County to enter upon the ave-menti ned pro erty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE e®_ fsS gnatur of Permittee Date T" LUUNTY OF LOS ANGELES T E, EL-ECTRICAL PERMIT DFPPRTMENT OF PUBLIC WORKS 9101 4 AS EL 0508 0410250f�,V. 3UILDIi','C, AND SAFETY LAND DEVELOPMENT TEM.PLE Cl'-"Y (;A 91780 P 1.--,26) 285-0488 EXT-. LEGAL ID: FEES P;, p D-ESS: TR: 36735 LT: 3 1 J 3 7 K E Y liw'E S r ST FEE DESCRIPTIllkl: QUANTITY: UQ.M.- AMOUNT: ASSESSOR INFORmAjION 1-DOSS '-STREET: HALIFAX ' 8585-018-067 Al PERMIT !SSL4,,�Nrr` `=EE 27.75 omA.s PAGP� 597 GRID: C4 'CALTEMPLE CITY, Cl Gl OUTLETS-L.G-.,S',,F.H'r- 14.00 OUT 27.30 r7T 6330 ISSUED CIN f F:T C TENANT: G2 LIGHTING 38.00 L TOTAL FEES 118.35 10/25/04 F FAL BY NU OWNER: TEL. R WONG, QUI NN/ST EP"A.-I'll (3273) ?,!�L-3443- 10307 KEY WEST TEMPLE CITY CA 91788 DESCRIPTION OF 14 OUTLET , AND 38 LIGHT FTX-""�'k;:� t; APPLICANT: T El. i,-- ,SAME AS OWNER SPECIAL TJ, N—s- 'S.-GNATURF. P k�v' DATE CGNTRACrOR: iSAME AS OWNER Ll . NO ;TQFRITECT ffrc E7— ILL. LIC. NO: 'ran.NT PLASTIC H',L.AL YIN UTILITY i —.;;N. REPORT ID: DPR265 ROUTE TO- BS0508