HomeMy Public PortalAbout6146 RENO AVE_Electrical__ WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12-91)76A66APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self Insure,
or a ceificate of Worker's Compensation Insurance, or a certified ' COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS BUILDING AND SAFETY DIV.
copy thel'edf(Sec.3800 Lab.C.) !
Policy No Compan / FOR APPLICANT TO FILL IN JODDRESS
Certified copy is hereby furnished. New Residential.Bldgs.&Pools NO. EACH FEE LOCALITY
1 &2-Family,Sq.R. — $ $
Certified copy is filed with the county building inspection _ NEAREST if
department. 0000 Multi-family Sq.Ft. CROSS ST.
Date licanf Residential Swimming PoolASSESSOR
MAP BOOK PAGE PARCEL
CERTIFICATE OF E N FROM WORKERS' Outlets:Rec._Light - Sw. OWA WOR
NAME
COMPENSATION INSURANCE FlRM NAME
First.20 MAIL
(This section need not be completed if the work Involved by the Total NoAdditional ADDRESS
permit.Is'for one hundred dollars($100)or less.) . _
I certify that in the performance of the work for which this permit CITY Tel.N . .
is issued, I shall not employ any person in any manner so as to PLAN CHECK
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 making 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
p Y p.y Power Apparatus&Large Appliances APPLICA .
provisions or this permit shall be deemed revoked.
LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRES �a
1 hereby affirm that I am licensed under provisions of Chapter 9 Over 3 to 10 Incl.
(commencing with Section 7000)of Division 3 of the Business and, CITY� Tel,
Professions Code,and my license is in full force and:effect. Over 10 to 50 Incl.
LICENSE OR Cl...
Over 50 to 100 Incl. REG.NUMBER d
Over 100 DISTRICT NO ESSED BY Q
License Number Lic.Class p V
• Sery Swbyd�,7MLC�C/.&P ne -�,�O �
D 0�399'Apl Un V �� FINAL 0
Contractor. .. p' DATE
400-1000 Amp.Under 600 V 5'2��1 VALIDATION V
I am exempt under Sec. Over 1000 Amp.or Over 600 VW
'B.&P.C.for this reason BRANCH CIRCUIT FEES Y AL a
Date: 15A,or 20A,120V,Lighting or Recept. Z
1 To 10 Branch Circuits
Signature 11 To 40 Branch Circuits
41 Or❑ re
Exemption for Reg.Maint.Elect. 15A,20A,208V To 277V Lighting Bra.nch Circuitsults 3303 73.60
SINGLE FAMILY Temp.Power Pole&Appurtenances ,,77vv77
HOMEOWNER-BUILDER DECLARATION 1 ITEMS
I hereby affirm that 1 am exempt from the Contractor's License Law Sign with One Branch Circuit
for the following reason (Section 7031.5, Business and Professions. Additional Sign Branch Circuits TOTAL 73.60
)
Code:
CHECK 73e60
F1 .1,
•as owner of the property,will do the work and:the structure Misc.Conduits&Conductors CHANGE •��
is not intended or offered for sale(Section 7044, Business let c Is.
and Professions Code).
CONSTRUCTION LENDING AGENCY -60
M-0001 4I16/96
1 hereby affirm that there is a construction lending agency for the i4
performance of the work for which this permit is issued (Sec. 3097, PERMIT FEE (Sub=Total) Q 5899 1 AM 8o40
Cly.C .)
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE a
Lender's Address
I certify that I have read this application and under penalty of purjury state TOTAL FEE r�
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 County to enter upon the above-mentioned property
for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
F PERMITTEE DATE
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 ELECTRICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS EL 0508 0809030039
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
LEGAL ID: I FEES PAID I BUILDING ADDRESS: I
1TR: 5904 LT: 69 1 1 6146 RENO AV I
I FEE DESCRIPTION: QUANTITY: UOM: AMOUNT:[ TEMP CA 917801532
ASSESSOR INFORMATION NUMBER: I I NEAREST CROSS STREET:
15384-004-007Al PERMIT ISSUANCE FEE 27.75 I THOMAS PAGE: 596 GRID: H2 LOCALITY: TEMPLE CITY, Cl
I IG1 OUTLETS-LGT,SW,RECP 1.00 OUT 1.95 1 1
(TENANT: IH7 RES EXHAUST FANS 1.00 EX 10.95 (ISSUED ON: PROCESSED BY: PLAN BY: EXPIRES ON:
I I TOTAL FEES 40.65 109/03/08 SR 03/02/09
(OWNER: TEL. NO: I IFI LDDAATTEE FIN Y: CODE., I
ISALINAS LAZARO �% Y O 1
16146 RENO AV I 1
ITEMP 917801532 IDEStRIPTION OF WORK I
I I 1PROVIDE & INSTALL EXHAUST FAN AND OUTLET (GFCI) AT BATHROOM 1
(APPLICANT: TEL. NO: { I I
ITAYLOR (626) 256-4535- 1 1
1P.0. BOX 284 1 ISPECZAL CONDITIONS: I
(TEMPLE CITY CA 91780
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ICONTRACTOR: TEL. NO: I (APPROVALS DATE INSPECTOR SIGNATURE I
ITAILORED ELECTRIC (626) 256-4535- I I 1
19541 E MARSHALL ST LIC. NO I ITEMPORARY POWER POLE I I I
IROSEMEAD CA 91770 678616 C10 I 1 I I
1 (UNDERGROUND CONDUIT I I I
[ARCHITECT OR ENGINEER: TEL. NO: IUFER GROUND I I I
LIC. NO: 1 TROUGH CONDUIT 1 1 1
1 TROUGH WIRING 1 I 1
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IMAIN WATER LINE I 1 1
1 I IPLASTIC YIN METAL YIN I I 1
1 I [UTILITY COMPANY NOTIFIED( I I
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1 IREPORT ID: DPR265 ROUTE TO: BS0508 1 I 1
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