HomeMy Public PortalAbout6202 RENO AVE_Electrical__ �',`�• WORKERS'COMPEIV$ATION DECLARATION P. CE-806G 10/81 APPUCATI®IV FOR ELECTRICAL PERMIT
I Hereby affirm that I have.a'certificate of consent to self insure, ,
or a certificate of Worllers' Compensation Insurance, or a certified 1' , . COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thQredf(Seco.38A0�0-,Lab.C.) c�,��•�. ��u J
Policy No. V 16`� pany- �U G�1� Lui N FOR APPLICANT TO FILL IN JOB
® Certified copy is hereby furnished. New Residential Bldgs.&Pools EACH NO. FEE ADDRESS
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❑ Certified copy is filed with the county building inspection 1 &2-Family,Sq.Ft. $ _ $ LOCALITY /
department. Multi-family Sq.Ft. NEAREST Al
_6 Applicant �'e— � C Residential Swimming Pools CROSS ST.. �/����
Date OWNER OR y�� }�� / Lq
p F FIRM NAME /1'1 I'� l.�l 0'� 46
CERTIFICATE OF EXEMPTION FROM WO ' Outlets:Rec Light J"Sw. 7d o �� 00 FIRM
MAIL
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RKERS
COMPENSATION INSURANCE ADDRESS SJI Q Gt S
(This section need not be completed if the work involved by the First 20
Total No. Additional D CITY
LANoJLq
permit is for one hundred dollars($100)or less.) PN CHECK
I certify that in the performance of the work for which this permit APPLICANT
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 Additional G ADDRESS
Date Applicant
Total No._ CITY Tel.No.
,
provisions of the Labor Code,you must forthwith comply with such Oven _ Dryer—F W.M._ ADDRESS /�
•NOTICE TO APPLICANT: If, after making this Certificate of Fixed Appliances Not Over 1 HP PERMIT
APPLICANT l,0 L/�it U H ?�J
Exemption,you should become subject to the Workers'Compensation Range_ Heater D.W. _ ry, f �'w� n
(�� O 9 Vl've We
provisions or this permit shall be deemed revoked. Top — FAU W.H. _ �U /O -0 CITY _,-p
LICENSED CONTRACTORS DECLARATION Hood — Fan Z Other_ � 6YG � (�d
I hereby affirm that I am licensed under provisions of Chapter 9 LICENSE OR t^
(commencing with Section 7000)0f Division 3 of the Business and Disp. — Room Air Cond. REG.NUMBER Class.
Professions Code,and my license is in full force and effect. DISTRICT NO. PROC SSE
Power Apparatus&Large Appliances
Q Size&Type HP,KW,KVA,or KVAR 09
License Number o Lic.Class Up to 1. Inc]. FINAL U
Contractor Date - 3 Over 1.to 1'0 Incl. DATE /�,� 3—,9 no/ VALIDATION
Over 10 to 50 Incl. FINAL
❑ I am exempt under Sec. Over 50 to 100 Inc. BY E/�_�
B.&P.C.for this reason
Over 100
Services,Swbd.,MCC&Panelboards Z
Date: 0-200 Amp.Under 600 V
Signature 201 - 1000 Amp.Under 600 V
❑
Exemption for Reg.Maint.Elect. Over 1000 Amp.or Over 600 V
SINGLE FAMILY Temp.Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License Law
for the following reason(Section 7031.5,Business and Professions Additional.Sign Branch Circuits 2
Code):- Misc.Conduits&Conductors �� '°s
❑
I,as owner of the property,will do the work and the structure �':�j'� -�
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) _ f .90
0
and Professions Code). q0' _19.913
CONSTRUCTION LENDING AGENCY ?�,.1 79.9-L-11 hereby affirm that there is a construction lending agency for the 4'I t
performance of the work for.which this permit is issued(Sec.3097, PERMIT FEE (Sub-Total) ;.
Civ.C.). t .. ° )
PLAN CHECKING FEE ,°tllf - 3'°, I
Lender's Name
PERMIT ISSUING FEE / D }yi �
Lender's Address _
I certify that I have read this application and state that the above TOTAL FEE
d
.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 L
Signature of Permittee Date
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 ELECTRICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS EL 0508 1309180059
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
[LEGAL ID: I FEES PAID I BUILDING ADDRESS:
ITR: 5904 IT: 66 I 1 6202 RENO AV 1
-IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT:[ TEMP CA 917801534
[ASSESSOR INFORMATION NUMBER: I NEAREST CROSS STREET:
15384-004-002 TAI PERMIT ISSUANCE FEE 27.80 THOMAS PAGE: 596 GRID: H2 LOCALITY: TEMPLE CITY CAI
I IG1 OUTLETS-LGT,SW,RECP 1.00 OUT 2.00 1 I
(TENANT: TOTAL FEES 29.80 [ISSUED ON: PROCESSED BY: PLAN BY: 1
I 109/18/13 SR
TOWNER: TEL. NO: 1 IFI DATE FI AL BY: CODE: I
IHSIA KUANG TSAN - I I
16202 RENO AV T I I
ITEMP 917801534 1 InESCRIPTION OF WORK I
I 1REPLACE OUTLET 1
(APPLICANT: TEL. NO: I I I
1FUNG, ROBERT (323) 633-1620-
600 N 18TH STREET T (SPECIAL CONDITIONS: T
TMONTEBELLO CA 90640 I I
(CONTRACTOR: TEL. NO: I (APPROVALS DATE INSPECTOR SIGNATURE 1
IROBERT L FUNG CONSTRUCTION (323) 633-1620- I 1 1
1600 NORTH 18 ST LIC. NO I ITEMPORARY POWER POLE I I
IMONTEBELLO, CA 90640 792204 I 1 1 I
[UNDERGROUND CONDUIT
(ARCHITECT OR ENGINEER: TEL. NO: 1 IUFER GROUND I I I
I LIC. NO: 1 1ROUGH CONDUIT I I I
1 I IROUGH WIRING
1 I I
I [MAIN WATER LINE I I I
I 1PLASTIC Y/N METAL Y/N I I I
I 1UTILITY COMPANY NOTIFIED[ I I
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IREPORT ID: DPR265 ROUTE TO: BS0508 [ I I I
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