HomeMy Public PortalAbout9810 RICHMOND WAY_Electrical__ WORKERS'COMPENSATION DECLARATION PLICATION FOR-683 tO/8t APELECTRICAL PERMIT {�
I hereby affirm that I have a certificate of consent to self insure, CE-806G APPLICATION �l LI
or a certificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof(Sec.3800,Lab.C.)
Policy No. Company FOR APPLICANT TO FILL IN JOB
ADDRESS
Certified copy is hereby furnished. New Residential Bldgs.&Pools EACH NO. FEE
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1 &2-Family,Sq.Ft. +D $ — $ d LOCALITY � M
Certified copy is flied with the county building inspection NEAREST ( n rAA1 ,/ n,,-�,'
department. Multi-family Sq.Ft. — IOr "/j(� L C�v>�
CROSS ST. G^O �� �
Date Applicant Residential Swimming Pools OWNER OR
FIRM NAME �+g tJ�✓ �GR�
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec—Light_Sw.— MAIL /�
COMPENSATION INSURANCE ADDRESS .L d7(� ,/��
First 20
(This section need not be completed if the work involved by the CIT a Iff Tel.No. Z gr3)t3
permit is for one hundred dollars($100)or less.) Total No. Additional
I certify that in the performance of the work for which this permit PLAN CHECK
Y P P 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 ADDRESS
.l� Total No. Additional CITY Tel.No.
Date�It)tea-� r8 Applicant 6-M 6 d'eenLr,'e' Fixed Appliances Not Over 1 HP PERMIT e
NOTICE TO APPLICANT: If, after making this Certificate Of APPLICANT /4t&e L
Exemption,you should become subject to the Workers'Compensation Range_ Heater D.W.
provisions of the Labor Code,you must forthwith comply with such Oven _ Dryer_ W.M._ ADDRESS , CN O -Z_Ct6
provisions or this permit shall be deemed revoked. Top _ FAU _ W.H. _ i
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LICENSED CONTRACTORS DECLARATION Hood — Fan _ Other_ CITY L' Tel.No.j ���
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. LICENSE OR �/v(-gy6 Gass
(commencing with Section 7000)of Division 3 of the Business and REG.NUMBER
Professions Code,and my license is in full force and effect. Power Apparatus&Large Appliances DISTRICT NO. PROCESSED BY >-
G ® 076L Size&Type HP,KW,KVA,or KVAR
License JVumber �eh Lic.Class �– Up to 1 Incl. FINAL U
/ Over 1 to 10 Incl. DATE
Contractor[�� �� Date 1d Zy FINAL VALIDATION 0
❑ Over 10 to 50 Incl.
I am exempt under Sec. Over 50 to 100 Inc. BY W
B.&P.C.for this reason Over 100 / N
4<–� Services,Swbd.,MCC&Panelboards
D 0-200 Amp.Under 600 V
es
: O"''Z Z
Signature ate201 - 1000 Amp.Under 600 V
❑ Over 1000 Amp.or Over 600 V
Exemption for Reg.Maint.Elect.
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
Code): �r9115.51C
Misc.Conduits&Conductors i T'�E
I,as owner of the property,will do the work and the structure +
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) _ _
and'Professions Code). _® �O T AL 115 o 50
CONSTRUCTION LENDING AGENCY CHECK f 1='°5I=
I hereby affirm that there is a construction lending agency for the
performance of the work for which this permit is issued(Sec.3097, PERMIT FEE (Sub-Total) CHA1,5E
Civ.C.).
PLAN CHECKING FEE
Lender's Name J UL00'0001 101/24/0/0
PERMIT ISSUING FEE /� � �,
3�r
Lender's Address 94 1 AM 10"2,t
I certify that I have read this application and state that the above TOTAL FEE
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
Signature of Permittee Date !
' COUNTY OF LOS ANGELES TEMPLE CITY # 0508 ELECTRICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS EL 0508 1008160012
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
LEGAL ID: I FEES PAID I BUILDING ADDRESS: I
TR: 43136 LT: 1 UN: 7 I I 9810 RICHMOND WY
(FEE DESCRIPTION: QUANTITY: UOM: AMOUNT:( TEMP CA 917803966 1
IASSESSOR INFORMATION NUMBER: I I NEAREST CROSS STREET: GOLDEN WEST
18589-020-085 1A1 PERMIT ISSUANCE FEE 27.80 I THOMAS PAGE: 597 GRID: A5 LOCALITY: TEMPLE CITY, Cl
[G1 OUTLETS-LGT,SW,RECP 2.00 OUT 3.90 1 1
TAT: [G2 LIGHTING FIXTURES 1.00 LGT 1.90 (ISSUED ON: PROCESSED BY: PLAN BY:
TOTAL FEES 33.60 08/16/10 SR
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TOWNER: TEL. N0: I I FINAL DATE FI Y: CODE:
ILIU, YANG(DAVID) (626) 297-7001- i 1o
19810 RICHMOND WA U
ITEMP 917803966 I IDESCRIPTION OF WORK
(ADD 2 OUTLETS AND 1 LIGHT FIXTURE
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(APPLICANT: TEL. N0:
ISAME AS OWNER _
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ISPECIAL CONDITIONS:
(CONTRACTOR: TEL. NO: i JAPPROVALS DATE INSPECTOR SIGNATURE
(SAME AS OWNER _
LIC. NO I ITEMPORARY POWER POLE
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(UNDERGROUND CONDUIT I I 1
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ARCHITECT OR ENGINEER: TEL. NO: I IUFER GROUND I I I
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LIC. NO: i IROUGH CONDUIT
1 (ROUGH WIRING /-(90�
IMAIN WATER LINE
(PLASTIC YIN METAL YIN �I I
1 [UTILITY COMPANY NOTIFIED(-1 I
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1 I I I I I
1 I I [
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REPORT ID: DPR265 ROUTE TO: BS0508 I I I I
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