HomeMy Public PortalAbout9822 RICHMOND WAY_Electrical__ WORKERS'COMPENSATION DECLARATION 76-863 to/et APPLICATION
(f9 P 1C9t,` ION FOR ELECTRICAL PERMIT {�
I hereby a>;firm that.l have a certificate of consent to self insure, CE-806G Ci I!m /•'Sti lil FOR L LJ
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
Certified co is hereby furnished. EACH NO. FEE ADDRESS �OT v- /� ,ryJ l.1rh
PY Y New Residential Bldgs.&Pools ��
❑ 1 &2-Family,Sq.Ft. $ _ $ /per / LOCALITY 1 ism i4B 4 C
Certified copy is filed with the county building inspection NEARESTy
OWNER
department. Multi-family Sq.Ft. CROSS G ,yl e 51
Residential Swimming Pools O
Date Applicant OR 1
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec—Light —Sw. — MAIL
COMPENSATION INSURANCE First 20 ADDRESS
(This section need not be completed if the work involved by the CITY Tel.No.
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
is issued, I shall not employ any person in any manner so as to APPLICANT $ GCI
become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS
eU
,,��±± Additional G 1'_M �.� ys . Total No. CITY Tel.No.
Date/ Applicant V
NOTICE TO APPLICANT: If, after making this Certificate of Fixed Appliances Not Over 1 HP PERMIT a
Exemption,you should become subject to the Workers'Compensation Range_ Heater_ DW APPLICANT �i')) �� - G
provisions of the Labor Code, you must forthwith comply with such Oven _ Dryer_ W.M._ ADDRESS OPV
provisions or this permit shall be deemed revoked. Top — FAU _ W.H. _ CITY &Jj ,1y L`� Tel.No.
LICENSED CONTRACTORS DECLARATION Hood — Fan _ Other_
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. LICENSE OR G�,(
(commencing with Section 7000) of Division 3 of the Business and REG.NUMBER !�3�IF
�' Class.
Professions Code,and my license is in full force and effect. Power Apparatus&Large Appliances DISTRICT NO. PROCESS BY
970
/ Size&Type HP,KW,KVA,or KVAR U -r��G�tiG�� 0
License Number
-I 97 2 Lic.Class C Up to 1 Incl. FINAL /IMY
n U
C3`i�1Y � b�- Date j� a-K� Over 1 to 10 Incl. DATE � l (, /, O
Contractor V VALIDATION
❑ Over 10 to 50 Incl. FINAL
I am exempt under Sec. Over 50 to 100 Inc. BYk1111.
W
B.&P.C.for this reason Over 100 A� N
Services,Swbd.,MCC&Panelboards / ' Z
ate: 0-200 Amp.Under 600 V rs
Signature pff 201 - 1000 Amp.Under 600 V t
❑ 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 Al, •- y
for the following reason(Section 7031.5,Business and Professions Additional Sign Branch Circuits
7
-�r
Code): =•.rte r i i.�o.ts
I,as owner of the property,will do the work and the structure Misc.Conduits& Conductors 1 i tN•=t
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule)
f UT1` y J 5 o4
and Professions Code).
CONSTRUCTION LENDING AGENCY C"i E U.
I hereby affirm that there is a construction lending agency for the CHANGE FIL
performance of the work for which this permit is issued(Sec.3097, PERMIT FEE (Sub-Total) ��
Civ.C.).
PLAN CHECKING FEE
Lender's Name 0,C01�„'.'—!'I])3 Z !C/214/91_1
/91_1
PERMIT ISSUING FEE �� �
Lender's Address _'-
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 0202060027
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
LEGAL ID: FEES PAID BUILDIN"DRESS:
TR: 43136 LT: 1 UN: 5 9822 RICHMOND WY
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917803966
ASSESSOR INFORMATIONEAREST CROSS STREET: GOLDEN WEST
8589-020-083 Al PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 597 GRID: A5 LOCALITY: TEMPLE CITY
G1 OUTLETS-LGT,SW,RECP 1.00 OUT 1.95
HA FAU LESS 3HP 1.00 FAU 10.95 ISSUED : PROCESSED Y: PLAN EXPIRES ON:
TOTAL FEES 40.65 02/06/02 JK 08/05/02
OWNER: TEL. 0: FI AL TE FINAL BY: CODE:
WILLIAM SANTILLIAN (626) 451-0938- a
9822 RICHMOND CT
TEMP 917803966 D SCR PSI N OF ORK
ADD SWITCH FOR FURNACE
APPLICANT: E
MARK S GLOVER (909) 279-0604-
5030 VICEROY AVENUE SPECIAL CONDITIONS:
NORCO 92860
CONTRACTOR: TEL. NO: APPROVALS DATE INSPECTOR SIGNATURE
AIR TRO, INC. (626) 357-5311-
1630 S MYRTLE AVE LIC. NO TEMPORARY POWER POLE
MONROVIA, CA. C36 C38 B
UNDERGROUND CONDUIT
ARCHITECT OR ENGINEER: TEL. 0: UF5R GROUND
LIC. NO: ROUGH CONDUIT
I
ROUGH R G
MAIN WATER LINE
PLASTIC Y/N METAL Y/N
UTILITY COMPANY O I E
* ADDITIONAL DATA ON FILE
REPORT ID: DPR265 ROUTE TO: 9S0508