HomeMy Public PortalAbout5735 RIO HONDO AVE_Electrical__ �8�, 1WORKERS'COMPENSATION DECLARATION 76-663 10/81 APPLICATION FOR ELECTRICAL PERMIT
a er m that I have a certificate of consent to self insure, CE-806G
or a certificate of Workers' Compensatiorl.Insurance, or a certified COUNTY OF LOS.ANGELES BUILDING AND SAFETY
cWY thereof(Sec.3800,Lab.C.)
Policy No. Company FOR APPLICANT TO FILL IN JOB
0 Certified copy js hereby furnished. EACH NO. FEE0—
ADDRESS ' ;�J. GO NDO
' New Residential Bldgs.&Pools LOCALITY
rl Certified copy is filed with the county building inspection 1 &2-Family,Sq.Ft. $ — $
department. Multi-family Sq.Ft. NEAREST a /,
CROSS ST.
` Residential Swimming Pools t OWNER OR 6A!T
Date Applicant FIRM NAME Q �i'a•�Fy
CERTIFICATE OF EXEMPTION FROM WORKERS'
' Outlets:Rec,0—Light *— Sw. 5:. MNL
COMPENSATION INSURANCE �, 1 " ADDRESS
(This section need not be completed if the work Involved by the First 20
permit is for one hundred dollars($100)or less.)
Total No. Additional CITY TeL No.
I certify that in the performance of the work foi'which this permit PLAN CHECK
APPuc-Nr
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
y Total No. Additional, CITY Tel.No.
Date A.I. Applicantc�� / Fixed Appliances Not Over 1 HP `
NOTICE TO APPLICANT: If, after making this Certificate of PERMIT
Exemption,you should:become.subject to the Workers'Compensation Range_ Heater D.W . APPLICANT
provisions of'the Labor Code,you must forthwith comply with such Oven - Dryer_'W.M.._ ADDRESS
provisions or this permit shall be deemed revoked. Top FA W H. _
LICENSED CONTRACTORS DECLARATION Hood Fan Other_ CITY Tel.No.
I hereby.affirm that I am licensed under provisions of Chapter 9 Disp LICENSE OR
(commencing with Section 7000)of Division 3 of the Business and Room Air Cond... REG.NUMBER Dom'
Professions Code,and my license is in full force and effect. Power Apparatus&Large ' DISTRICT NO�1 , 1I` r/ PROCESSE Appliances +
Size&Type HP,KW,KVA,or KVAR Q�
License Number Lie.Class Up to 1 Incl. FINAL �+
Over 1 to 10 Incl.
Contractor Date U VALID ION 0
❑ Over 10 to 50 Incl, 111}......'...
I afn exempt under Sec. Over 50 to 100.Inc. ;wW
BAP.C.for this reason Over 100 N
Services,Swbd.,MCC.&Panelboards Z
Date: 0-200 Amp.Under 800 V. A
Signature 201 - 1000 Amp.Under 800 V
E] Exemption.for Reg..Maint.Elect. Over 1000 Amp.or Over 600 V .28824A
JINGLE FAMILY Temp.Power Pole.&Appurtenances # 000002
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
1 hereby affirm that['am exempt from the Contractor's License Lawo 0
for the following reason(Section 7031.5,Business and.Professions Additional Sign Branch Circuits 6 0
Code): .0 °.° 6 3 C 0.
Misc.Conduits&Conductors
I,as owner of the property,will do the work and the structure Other(See Complete Fee Schedule) _ 1,2 2—8 8
r 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 w4lch this permit is issued(Sec.3097, PERMIT FEE (Sub Total)
Civ.C.).
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE v;
Lender's Address �T D
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 insp ctidn purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE "
yY Sv -
Ig ature ofmittee Date
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 ELECTRICAL PERMIT
-• DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS EL 0508 0304150008
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
LEGAL ID: S PAID BUILDING ADDRESS:
TR: 6561 LT: 1 UN: .002 5735 RIO HONDO AV
FEE DESCRIPTION: QUANTITY: LION: AMOUNT: TEMP CA 917802433
ASSESSOR INFORMA0 R: NEAREST CROSS STREET: LIVE OAK
8587-003-011 Al PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 596 GRID: J3 LOCALITY: TEMPLE CITY
F1 120V, 15/20A BR CKTS 2.00 BR 34.50
G1 OUTLETS-LGT,SW,RECP 20.00 OUT 39.00 .
G2 LIGHTING FIXTURES 6.00 LGT 11.70 05/19/03 JK 11/15/03
TOTAL FEES 112.95
OWNER: TEL. 0: FINAL DATE FINAL BY: CODE:
WANG;JIAN JUN (626) 337-1863- /
5735 RIO HONDO b-Zd 03
TEMPLE CITY DESCRIPTION
ELECTRICAL FOR ADDITION
APPLICANT:
NICK TIMKO (909) 392-8287-
4095 N FRUIT ST #809 SPECIAL CONDITIONS:
LA VERNE
CONTRACTOR: TEL. NO: APPROVALS DATE I SP CTOR SIGNATURE
NICKIS REMODELING (909) 392-8287-
4095 N FRUIT STREET LIC. NO TEMPORARY POWER POLE
SPACE 809 409663 B
LA VERNE, CA 91750 UNDERGROUND CONDUIT
ARCHITECT0 0: UFER GROUND
LIC. N0: ROUGH CONDUIT
ROUGHR NG
MAIN-WATER LINE
PLASTIC Y/N METAL Y/N
UTILRY COMPANY 0 IF D
REPORT ID: DPR265 ROUTE TO: BS0508