HomeMy Public PortalAbout6156 RENO AVE_Electrical__ WORKER'S COMPENSATION DECLARATION 177M063 DPW(12-91) APPLICATION FOR ELE�EORKS
TRICAL PERMIT
I hereby affirm that I have a certificate of consent to self insure,
or a certificate of Worker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT.OF PUBLIC I BUILDING AND SAFETY DIV.
copy thereof(Sec.3800 Lab.C.) /,!y
Policy No.��/ 97 Company STATE FyyP FOR APPLICANT TO FILL IN ~ JOB
ADDRESS CIO/S�j N jr/v
Certified copy is hereby furnished. NO. EACH FEE
New Residential Bldgs.&Pools
$ $ LOCALITY L
Certified copy is filed with the county building inspection 1 &2-Family,Sq.Ft. NEAREST
department. [J Multi-family Sq.Ft. — CROSS sT.
Date ��� / / Applicant /YJDAJTiF -f�L/9N7X�f Residential Swimming Pools ASSESSOR
_ MAP BOOK PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec._Light Sw. OWNER OR
COMPENSATION INSURANCE FIRM NAME
First 20 MAIL /�`�,-/ �D
(This section need not be completed If the work Involved by the Total No. Additional ADDRESS (� (�
permit is for one hundred dollars(5100)or less.)
I certify that in the performance of the work for which this permit CITY GTel.No.ag'7
is issued, I shall not employ any person in any manner so as to PLAN CHECK
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become subject to the Workers'Compensation Laws. I Lighting Fixtures. First 20 APPLICANT
Total No. Additional ADDRESS
Date Applicant I RESIDENTIAL.APPLIANCES NOT OVER 3 HP.
1
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.
, C
provisions of the Labor Code,you must forthwith comply with such PERMIT
provisions or this permit shall be deemed revoked. Power Apparatus&Large Appliances APPLICANT X174� N F 244 191A
LICENSED CONTRACTORS DECLARATION I Size&Type HP,KW,KVA,or KVAR ADDRESS�$
I hereby affirm that 1 am licensed under provisions of Chapter 9LOU JtV
Over 3 to 10 Incl. CITY Tel.No.
(commencing with Section 7000)of Division 3 of the Business and S,,W .(j�Q,B L off$
Professions Code,and m license is in full force and effect. Over 10 to 50 Incl. •
y I LICENSE B Clasa.
I ••Over 50 to 100 Incl. REG.NUMBER
License Number GAG o 130 r Lie.Class G i Over 100 DISTRICT NO.
S ryyices, b OC&yp Iboar Q
��,pp/��� �6'D GLi1J FINAL
Contractor�e���« LM__bate —3 O—Q I Amp er V DATE O
❑ 400-1000 Amp.Under 600 V Z ` IL)
I am exempt under Sec. VALIDATION W
i Over 1000 Amp.or Over 600 V FINAL
B.&P.C.for this reasonBY BRANCH CIRCUIT FEES a
Date: 15A,or 20A,120V,Lighting or Recept. Z_
1 To 10 Branch Circuits
Signature I 1 To 40 Branch Circuits
❑ 41 Or More Branch Circuits
Exemption for Reg.Maim.Elect. i 15A,20A,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 =�
for the following reason(Section 7031.5, Business and Professions + Additional Sign Branch Circuits 711,7
Code): i- 6—T-56—T-51,as owner of the property,will do the work and the structure �.s_`
Misc.Conduits&Conductors _ .s €TE.1E
is not intended or offered for sale(Section 7044, Business I Other(See Complete Fee Schedule) i',.TAL .6-3 - 45
and Professions Code). _
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the I •MANGE
performance of the work for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total)
Civ.C.) I
PLAN CHECKING FEE I Utl3— fL)i 1,218,19Z,
Lender's Name
PERMIT ISSUING FEE Q tY T i (=if fiU: =i
Lender's Address
e TOTAL FEE
I certify that I have read this application and under penalty of purjury stat (�
-that the above information is correct. I agree to comply with all County 5
ordinances and State laws regulating Electrical wiring,and hereby authorize
representatives of this County to enter upon the above-mentioned property
for inspection purposes. I SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE OF PERMI O E
i
COUNTY`OF'LOS ANGELES TEMPLE CITY # 0508 EL'ECTR'ICAL PERMIT
,-_WARTMENT OF PUBLIC WORKS 1 9701 LAS TUNAS EL-4508-9903300004
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
LEGAL ID: FEES PAID BULLDTIVG-AD SS:
TR: 5904 LT: 68 6156 RENO AV '
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEAP-_CA 917801532
ASSESSOR INFORMATION NEAREST CROSS STREET: GARIBALDI
5384-004-005 Al PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 596 GRID: H2 LOCALITY: TEMPLE CITY
G1 OUTLETS-LGT,SW,RECP 3.00 OUT 5.85
ENA TOTAL FEES 33.60 ISSUED : PROCESSED BY: EXPIRES ON:
03/30/99 UT 03/30/00
OWNER: TEL. NO: FINAL DATE FINAL ODE:
KOHLER EMILIE A TR EMILIE A KOHLER -
6156 RENO AV
TEMP 917801532 DESC 0
3 NEW GFICIS - HOUSING REHA ATION
PPL O:
BASHFORD ENTERPRISES (626) 443-4833-
12155 PINEVILLESPECIAL CONDITIONS:
EL MONTE, CA
�NGE�ES C�
CONTRACTOR: TEL. NO: APPROVALS DATE INSPECTOR SIGNATURE
BASHFORD ENTERPRISES (818) 443-4833- V
12155 PINEVILLE ST LIC. NO TE14PORARY POWER-POLE
EL MONTE, CA 91732 319112B
/ UNDERGROUND CONDUIT
ARCHITECT OR ENGINEER.-- TE 0: - P/ ER. GRO ND
LIC. N01 1111111 0 GH CONDUIT
r—
ROUGFUIRING
U D L C ��j O AIN WATER LINE
�I u PLASTIC Y/N METAL Y/N
UTILITY COMPANY NOTIF D
p po S6 181 i
Z7 0
5
48'x° Sepv�e Tha�`����
REPORT ID: DPR265 ROUTE TO: BS0508