HomeMy Public PortalAbout9628 LONGDEN AVE_Electrical__ r ;, �WORKERS'COMPENSATION DECLARATION 20-0019 DPW 3/87
76Ay63, APPLICATION FOR ELECTRICAL PERMIT
trt'rft-c-IcopV-fhe.reof
affirvyi that I havena certifioate of consent to self CE-8M
0suor a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
br a (Sec. 3800 Lab. .) -
Policy No.�[w Compan FOR APPLICANT TO FILL IN JOB
❑Certified copy is hereby furnished. New Residential Bldgs. &Pools EACH NO. FEE ADDRESS
r—LCertliled co. is filed with the count buildinginspec- 1 &2-Family, S Ft. $ — $ LOCALITY
copy y p y� q NEAREST
t'io epartmenf. Multi-family Sq. Ft. — •ti
Residential Swimming Pools OWNER CROSS O
Date Applicant R
e 1 �'
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' O s
COMPENSATION INSURANCE Outlets: R y Lightz Sw._ AD 14to section need not be completed if the work involved by First 20 Tel. No.
CITY ,,JJ
the permit is for one hundred dollars($100)or less.) Total No. Additional ` `Vh
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 Lighting Fixtures First 20 ADDRESS
so as tobecome subject to the Workers'Co pens io ws.
Additional
Date Applicant 'Total No. CITY T o:
NOTICE TO APPLICANT- If; after making this Certificate of Fixed Appliances Not Over 1 HP' PERMIT
Exemption, you should become subject to the Workers' Range— Heater—D.W.—
APPLICATION
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- —W.H. —
deemed revoked. Hood Fan `Other— CITY Tel. No.
LICENSED CONTRACTORS DECLARATION LICENSE OR
—— Z
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. Room Air Cond. REG. NUMBER 0 Class&
(commencing with Section:7000.)of Division 3 of the Business Power Apparatus&Large Appliances DISTRICT NO. ^ PROCESSED By d
and Professions Code,and my license is in full force and effect.
Size&Type HP, KW, KVA, or KVAR CJ L O
License Number Lic.Class —
Up to'l Incl. FINAL
Over 1 to 10 Incl. DATE r r " V TION
Contractor Date Over 10 to 50 Incl. v U
F-1FIN
I am exempt under Sec. Over 50 to 1.00 Inc. gY W
B:&P.C. for this reason Over 100 tL
®
Services, Swbd., MCC&Panelboards Z
Date: Z0-200 Amp. Under 600 V
Signature 201 - 1000 Amp. Under 600 V
❑ Over 1000 Amp. or Over 600 V
Exemption for Reg. IVlaint. Elect.
SINGLE FAMILY Temp. Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION o o+0 0 0
I hereby affirm that I am exempt from the Contractor's License Sign with One Branch Circuit # 2
Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits m o $ �, b
Professions Code)-
❑ I, as owner of the property, will do the work and the
$`1, (�
Misc. Conduits&Conductors o a 0. 'Q U
structure is not intended or offered for sale(Section 7044, Other(See Complete Fee Schedule)_ 1 6-88
Business and Professions Code). Q
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.).
Q PLAN CHECKING FEE
Lender's Name " PERMIT ISSUING FEE U
Lender's Address
I certify that C have read this application and state that the TOTAL FEE I
above information is correct. I agree.to.comply with all County
ordinances and.State laws regulating Electrical wiring, and
hereby authorize representatives of thi my to enter upon
the a
b. ned rop for i ecti purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signa ure LOUFe ®°
COUNTY OF LOS ANGELES TEMPLE CITY 9 0508 ELECTRICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS EL 0508 9905260002
• BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
- LEGAL D: S PAID BUILDING D SS:
ON FILE 9628 LONGDEN AV
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA.917801447
ASSESSOR 1 0 0 N R: NEAREST CROSS STREET: TEMPLE CITY BLVD
5385-016-008 Al PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 596 GRID: J2 LOCALITY: TEMPLE CITY
F1 120V, 15/20A BR CKTS 1.00 BR 17.25
TOTAL FEES 45.00 ISSUED 0 PROCESSED B L Y: EXPIRES ON:
05/26/99 UT 11/22/99
OWNER: TEL. NO: FINAL DATE FINAL BY: C
RAINE ALFRED B;CAROL J TRS (818) 447-6454- �e-
1740 HOLLY AV J sItz
!�
ARCD 910077943 DESCRIPTION OF WORK
NEW CIRCUIT FOR GARAGE
APPLICANT: TEL. 0:
SAME AS OWNER -
SPECIAL CONDITIONS:
�N(;IEEE LES CC
CONTRACTOR: TEL. NO: ®�✓ L�/j. + APPROVALS DATE INSPECTOR SIGNATURE
SAME AS OWNER
LIC. NO TEMPORARY POWER POLE
\\ UNDERGROUND CONDUIT
RC I ECT OR. G ER: TE 0: /'/ �' FER GROUND
LIC.-NO 11111'11 ROUGH CONDUIT
ROUGH I G
UD L� �Vlt 'J� `� PLASTICTER Y/NLINE METAL Y/N
`/`v/ _v- UTILITY COMPANYNOTIFIED
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REPORT ID: DPR265 ROUTE TO: BS0508