HomeMy Public PortalAbout6460 LIVIA AVE_Electrical__ WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12-91) APPLICATMN FOR ELECT MCAL PERM �
'
1 hereby affirm that ( have a certificate of consent to self Insure, 76A663
or a certificate of worker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV
copy thereof(Sec 3800 Lab C)
Policy N6 Company FOR APPLICANT TO FILL IN JOB
Certified co is hereby furnished ADDRESS
PY Y New Residential Bldgs &Pools NO EACH FEE
LOCALITY
❑ 1 &2-Family,Sq Ft — $ $'
Certified copy is filed with the county building Inspection NEAREST
- department Multi-family Sq Ft CROSS ST
Date ° Applicant Residential Swimming Pools _ ASSESSOR Q
_ MAP BOOKPAGE O PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets Rec Light SW OWNERNoR_
_ p� O AMED [�
COMPENSATION INSURANCE FIRM
First 20 a
(This section need not be completed if the work'involved by the MAIL
ADDRESS
perm itis for one hundred'dollars($100)or less Total No Additional)• ` -
I certify that in-the performance of the'�vork for which this permit CITY Tel124 51 9sL
is issued, I'shall not employ any person in any manner'so as t0, 4 PLAN CHECK - 7"
become,subject.to the Workers'Compensation Laws - Lighting Fixtures First 20 APPLICANT '
Total No Additional ADDRESS ,
Date Applicant RESIDENTIAL APPLIANCES NOT OVER 3 HP
NOTICE TO APPLICANT If, after,makmg this,Certificate of CITY Tel No
Exemption,you should become subject to the Workers'Compensation OTHER APPLIANCES NOT OVER 3 HP
provisions of the Labor Code, you must forthwith comply with such PERMIT
provisiohs or this permit shall tie deemed revoked Power Apparatus&Large Appliances APPLICANT
A LICENSED CONTRACTORSiDECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS
I hereby affirm that I am hcensed'u'nde� provisions'of Chapter 9 Over 3 to 10 Incl
(commencing with Section 7000) of Division 3 of the Business and CITY Tel No
Professions Code,and my license is in full force and effect Over 10 to 50 Incl'
Over 50 to 100 Incl LICENSE B Class }
,• REG NUMBER d
Over 100 - DISTRICT NO SSED BY 0
License Number Lic Class V
- Services,Swbd,MCC&Panelboards � cc
Contractor
0-399 Amp Under 600 V FINAL Q
Date _ DATE
❑ 400-1000 Amp. , Under 600 V
I am exempt under Sec Over 1000 Amp or Over-600 V FINAL ! VALIDATION W
-B&P C for this reason BRANCH CIRCUIT FEES BY n-
Date 15A,or 20A, 120V,Lighting or Recept _ 444 Z
1 To 10 Branch Circuits
Signature 11 To 40 Branch Circuits
41 Or More Branch Circuits
❑ Exemption for Reg Maint Elect 15Ar20A,208V To 277V Lighting Br Circuits
SINGLE FAMILY Temp Power Pole&Appurtenances )
HOME OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit Ti_I j Ai60,
for the following reason (Section 7031 5, Business and Professions Additional Sign Branch Circuitsen
,s[C ":1-7 _
Code) - - t„SICi,E' L..�
❑ I, as owner of the property,will do the work and the structure Mlsc Conduits&Conductors
C:H i GE--_ _ cy I
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) _
and Professions Code) D,
CONSTRUCTION LENDING AGENCY Q000-1110101 IL2/ J ,-+-
I hereby affirm that there is a construction lending agency for the y 't•6
performance of the work for which this permit Is issued (Sec 3097, PERMIT FEE (Sub-Total)
Civ C) _
PLAN CHECKING FEE
Lender's Name `L
PERMIT ISSUING FEE Tv
Lender's Address
I certify that I have read this application and under penalty of purjury state TOTAL FEE
that the above information Is correct I agree to comply with all County
ordinances and State laws regulating Electrical wiring,and hereby authorize
representatives of this Count to enter upon the above-mentioned property
for ins ecti purposes N, / SEE REVERSE FOR EXPLANATORY LANGUAGE
RE OF PER i /
DATE
COUNTY.OF LOS ANGELES TEMPLE CITY # 0508 ELECTRICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS EL 0508 0005020001
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
G FEES PAID BUILDINGADDRESS:
TR: 12504 LT: 15 6460 LIVIA AV
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917801329
ASSESSOR R ON BER: NEAREST CROSS STREET: LONGDEN
5382-018-003 Al PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 596 GRID: H1 LOCALITY: TEMPLE CITY
C2 SPAS, HOT TUBS, OTHR 1.00 SPA 54.45
EN F1 120V, 15/20A BR CKTS 2.00 BR 34.50 ISSUED ON: PROCESSED BY: PLAN BY: XPIR N:
HA FAU LESS 3HP 1.00 FAU 10.95 05/02/00 UT 10/ 00
JB AC UNITS +3-10HP 1.00 AC 19.65
OWNER: TEL. NO: TOTAL FEES 147.30 FINAL DATE FINAL BY: CODE:
LOK;HARRY (626) 288-3501- EJ,-
6460 LIVIA AV
TEMP 917801329 ESC IPTI N OF WORK
ELECTRICAL FOR REMODELING
APPLICANT: TEL. NO:
SAME AS OWNER
SPECIAL CONDITIONS:
S C®
CONTRACTOR: TEL. NO: ®� �/� APPROVALS DATE INSPECTOR SIGNATURE
SAME AS OWNER
LIC. NO TEMPORARY POWER POLE
UNDERGROUND CONDUIT
ARCHITECT TEL. NO: �� UFER GROUND
LIC. N0: 1111111 ROUGH CONDUIT
NROUGH WIRING
MAIN WATER LINEGU C
PLASTIC Y/N METAL Y/N
TILITY COMPANY NOTIFIED
O D
0
4g��c El �Q
Sea'vice"Th�$�
REPORT ID: DPR265 ROUTE TO: BS0508