HomeMy Public PortalAbout5756 LOMA AVE_Electrical__ WSTRK'ERth COMPENSATION DECLARATION 76A663CE-806 local
O _! herby1'u�ffir�n that I have a certificate of consent to self CE-806G APPLICATION FOR ELECTRICAL PERMIT
r 'rin5wre, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certifie copy thereof (Sec. 3800, Lab. C.)
Policy No.K40 170Company r?%A'1212-)Z2 FOR APPLICANT.TO FILL IN JOB r^
Certified co is hereb furnished. EACH ' NO. FEE ADDRESS
PY Y New Residential Bldgs. & Pools
a
Certified copy is filed with the county building inspec- 1 & 2-Family, Sq. Ft. $_4—' — $ LOCALITY C /4
tio4dae artment.
Multi-family-Sq. Ft. — 'NEAREST
/ CROSS ST. I V
(r/} /Pj� � Residential Swimming Pools OWNER OR
Date Applicant s LL�-f[ ,`' FIRM.NAME P $ / ({ /�1 C7 W
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Recti Light Sw.j MAIL
COMPENSATION INSURANCE ADDRESS
This section need not be com feted if the work involved b First do
20.
( p Y Total No. Additional �' CITY Tel. No.
the permit is for one hundred dollars ($100)or less.)
I certifythat in the of the work for which this PLAN CHECK
e performance 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
NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT o?
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 y
with comply with'such provisions or.this Permit shall.be
Top FAU feffW.H. —
deemed revoked. Hood Fan _Other_ CITY, -b►�l � Tel. No. 6 g
LICENSED CONTRACTORS:DECLARATION LICENSE OR
�j SCJ J S�
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. Room Air Cond. REG. NUMBER Class.-gt
(commencing with Section 7000) of Division,3 of the Business DISTRICT NO. PROCESS
Power Apparatus& Large Appliances �
and Professions Code,and my license is in full force and.effect. ' /1 �
� �. Size &Type HP, KW, KVA, or KVAR' 15, (/ 0
License Number Lic. Class Up to 1 Incl FINAL V
A���11Y Over 1 to 10 Incl. DATE � VALIDATI 0
ContractorC4, o d`� /T Date Over 10 to 50 Incl. FIN vvv U
❑ I am exempt under Sec. Over 50 to 100 Inc., BY W
Over 100 �' 2.1 0
B.&P.C. for this reason H
Services, Swbd., MCC& Panelboards r # o',o o,.o lo'2 7
Date: 0 -200 Amp. Under 600 V.
Signature 201 - 1000 Amp. Under 600 V ;,� o 0 5 k10,0
❑ Over 1000 Amp. or Over 600 V
Exemption for Reg. Maint. Elect. o'-'- 5 IL 0 0(=j
SINGLE FAMILY Temp. PowerPole &Appurtenances
HOME OWNER-BUILDER DECLARATION .1.0 9.-8 4
Sign with One Branch.Circuit
I hereby affirm that I am exempt from the Contractor's License Additional Sign Branch Circuits
Law'for the following reason (Section 7031.5, Business and
Professions Code):
❑ 1, 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)_
7044, Business and Professions 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 V
Lender's Name Sr
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
hereby authorize representatives of this County to enter upon
t e Bove-mentioned property for inspection purposes.
� SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee . Date,
' COUNTYOFLOS ANGELES TEMPLE CITY # 0508 ELECTRICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS EL 0508 1207170019
BUILDING AND SAFETY / LAND DEVELOPMENT ,TEMPLE CITY CA 91780
.PHONE: (626). 285-0,488 EXT:
ILEGAL ID: 1 - FEES PAID BUILDING ADDRESS: - 1
1 ON FILE - 1 : ' 'I 5756 LOMA AV
1 IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT: ( TEMP CA 917802452 1
IASSESSOR .INFORMATION NUMBER: - 1 NEAREST CROSS STREET:_ _'. - 1
15387-017-017 - 1A1 PERMIT ISSUANCE FEE 27.80 I THOMAS PAGE: 596• GRID: H3 LOCALITY: TEMPLE CITY CAI
I - IG1 OUTLETS-LGT,SW,RECP 5.00 OUT 10.00 - 1
(TENANT: - IG2 LIGHTING FIXTURES 13.00 LGT 26:00 1ISSUED.ON: PROCESSED BY: PLAN BY: - 1
1 1H4 RES RANGE HDS LT 3HP 1.00 HOO 11.00 107/17/12 SR '• 1
1 1 TOTAL FEES 74.80 I 1
(OWNER: - TEL. NO: 1FINAL DATE FINAL BY: - - - CODE: 1
1HERMOSILLO, SUSAN . (626) 485-5845- ( '
.1.5756 LOMA AV -
(TEMP 917802452 - IDESCR'IPTION OF WORK
1 I 11NSTALL 13 RECESSED LIGHTING IN LIVING ROOM, KITCHEN, 5
I 1 (OUTLETS AND RANGE HOOD
1APPLICANT: - - TEL. NO: I -
(SAME AS OWNER
I I (SPECIAL CONDITIONS: '
I
1CONTRACTOR: - - TEL. NO: I (APPROVALS DATE INSPECTOR SIGNATURE
ISAME AS OWNER
I LIC. NO _ ITEMPO_RARY POWER.POLE I _ .
I I 1UNDERGROUND CONDUIT I
I I I I I 1
ARCHITECT OR ENGINEER: - - TEL. NO: - IUFER GROUND
-� LIC. NO: IROUGH CONDUIT I
1 I 1ROUGH WIRING
( I
- (MAIN WATER/..LINE' � �
T
1 1
EXPIRED' 1PLASTIC Y/N METAL ,Y/N 1 I 1
I I UTILITY COMPANY .NOTIFIED
I I I 4 I i
I y 1 I 1 I
I i I I I I
I I I I L I
I I I I I
I I I i I I
1 (REPORT ID: DPR265 ,ROUTE TO: BS0508
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