HomeMy Public PortalAbout5716 RIO HONDO AVE_Electrical__ WORKERS'COMPENSATIONDECLARATION
CE-SOSG (2.80)' APPLICATION FOR ELECTRICAL PERMIT
E$06
I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY
insure,or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec.3800,Lab.-C.)
FOR APPLICANT TO FILL IN JOB �O /D�
Policy No. Company_ ADDRESS v
,. New Residential Bldgs.&Rools EACH NO. FEE
❑ Certified copy is hereby furnished. $ — $ LOCALITY �' a�
.. p 1 &2-Family,Sq. Ft.
copy is filed with the count Multi-family Sq. Ft. NEAREST
Certified co y buildin g i pection CROSS ST
department. Residential Swimming Pools �% s:,. O��
OWNER OR
FIRM NAME S Q: Cxs
Date Applicant Outlets: Rec. — Sw. MAIL
First 20 ADDRESS rwe
CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. Additional CITY ��� Tel No.
COMPENSATION INSURANCE PLAN CHEC
IC
APPLICANT n'
(This section need not be completed if the work involved. O
by the permit is for one hundred dollLighting Fixtures First 20 ADDRESS 0
ars ($100) or less.) Additional
Total No.
I certify that in the performance of the work for which this Fixed Appliances Not Over 1 HP CITY Tel No. - U
permit is issued, I shall not employ any person in any manner PERMIT
so as to become subject to the Workers'Compensation Laws. Range_Heater D.W._ APPLICANT LU
Oven _ Dryer_W.M._ ADDRESS N
Top _ FAU _W.H.._ ?
Date Applicant
• Hood — Fan —Other
CITY Tel No.
NOTICE TO APPLICANT: If, after making.this'Certificate of Disp. _Room Air Cond-_ LICENSE OR
Exemption, you should become subject to the Workers' RE.G..NUMBER Class
Compensation,provisions of the Labor Code, you must forth- power Apparatus,&Large Appliances i DISTRICT NO. PROCESSED BY
with comply with such provisi6ns or this permit shall be.
deemed revoked. Size&Type HP,KW,KVA,or KVAR Q or
Up to 1 Incl. S r,
FINAL
LICENSED CONTRACTORS DECLARATION Over 1 to 10 Incl. DATE , S i ,.r VALIDATION
Over 10 to 50 Incl.
t
I hereby affirm that I am licensed,under provisions of Chapter Over 50.to 100 Inc. BY !FINA.Lf,,
9 (commencing with Section 7000)of Division 3 of the Busi- Over 100
ness and Professions.Code, and'my license is in full force and
effect. Services
1 16 10
License.Number' Lie.Class 0-200 Amp.Under 600 V
201-1000 Amp.Under 600 V
Contractor Date Over 1000 Amp.:or Over 600 V
HOME OWNER-BUILDER DECLARATION Temp.Power Pole&Appurtenances
I hereby affirtn that I am exempt from the Contractor's Sign with One:Branch.Circuit i 5 0
License Law for the following reason (Section.7031..5, Busi-, Additional Sign Branch Circuits
n;ZssaProfessions Code): 4 o 7 �,6 2Misc.Conduits&Conductors0 '`� _8 2as owner of the property, will do the work and the Other(See Complete Fee,Schedule)— �'
structure is not intended or offered for sale (Section
7044,Business and Professions.Code).
CONSTRUCTION LENDING AGENCY
I hereby_ affirm that,there is a construction lending agency
for the performance. of the work for which this permit is. PERMIT FEE' '
issued(Sec.3097,Civ.C.). (Sub-Total)
Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee) 1 5 0 0.2 A
Lender's Address !PERMIT ISSUING FEE t# 0 0 0 0 0 2
I certify that I have read this application and state that the • , .TOTAL FEE 3 2.o - 2350
above information is correct.I agree to comply with.all,County
ordinances. and State laws regulating Electrical wiring, and 0 a 0 2 31 5 0
hereby authorize representatives of this County to enter upon i
the above-mentioned property for inspection purposes. \ SEE'REVERSE FOR EXPLANATORY LANGUAGE ; 07. 1 6=82
Signature CKrmfittee Date
i
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 ELECTRICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS EL 0508 1311200072
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
LEGAL ID: I FEES PAID I BUILDING ADDRESS: I
TR: 6561 IT: 757 UN: .004 I 1 5716 RIO HONDO AV I
IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT:1 TEMP CA 917802432 1
(ASSESSOR INFORMATION NUMBER: I I NEAREST CROSS STREET:
18587-004-006Al PERMIT ISSUANCE FEE 27.80 I THOMAS PAGE: 596 GRID: J3 LOCALITY: TEMPLE CITY CAI
I JHA FAU LESS 3HP 1.00 FAD 11.00 1
[TENANT: JB AC UNITS +3-10HP 1.00 AC 19.70 (ISSUED ON: PROCESSED BY: PLAN BY:
I i TOTAL FEES 58.50 111/20/13 SR 1
(OWNER: TEL. NO: [ IFINAL FIN&L CODE: 1
[OLMOS CARLOS M;SILVIA A;OLMOS CESAR (626) 292-5706- [ [ r /-f
15716 RIO HONDO AV I IL
ITEMP 917802432 1 JOESCRIPTION OF WORK
I I 1ELECTRICAL FOR A/C AND FAU UNITS 1
(APPLICANT: TEL. NO: 1 I I
IKACHIKIAN, VIGAN (818) 612-5276- 1 1
15467 SAN FERNANDO RD I ISPECIAL CONDITIONS: 1
1LOS ANGELES CA 90039 I I
i YD I
ICONTRACTOR: TEL. NO: 1 1APPR� DATE INSPECTOR SIGNATURE 1
IPRECISE AIR SYSTEMS, INC. (818) 240-1737- 1 1- I
15467 SAN FERNANDO ROAD LIC. NO ITEMPPDRARY POWER POLE I
IWEST LOS ANGELES CA 90039 428900 * 1 1 I I I
I I 1UNDERGROUND CONDUIT I I I
1ARCHITECT OR ENGINEER: TEL. NO: - 1 1UFEP, GROUND I I
1 LIC. NO: 1 IROUGH CONDUIT I I
IROUGH WIRING
I 1 IMAIN WATER LING
I 1 IPLASTIC YIN METAL YIN
I 1 1UTILITY COMPANY NOTIFIED( I I
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1* ADDITIONAL DATA ON FILE 1 1 1
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IREPORT ID: DPR265 ROUTE TO: BS0508
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