HomeMy Public PortalAbout6167 SULTANA AVE_Electrical__ ` .' WORKERS'COMPENSATION DECLARATION 10/81 APPLICATION FOR ELECTRICAL PERMIT
' I herel$ a#f' y' CE-&6G m,that I have a certificate of consent to self CE-e07�
�`•:.Insug or a ce►tificofe of Workers'Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY I(f'
or a cel'iified copy thereof(Sec. 3800, La )
'Policy No._ ompon / FOR APPLICANT TO FILL IN JOB /
❑ Cerfifie8 copy is hereby furnished. EACH NO. FEE ADDRESS (A
New Residential Bldgs. &Pool
1 &2-Family, S Ft. 's s — $ LOCALITY
Certified copy is filed with the county building inspec- Y q•
tion department. 1 Multi-family Sq. Ft. — NEAREST
t / Residential Swimming Pools CROSS ST.
1
Date i ..ApplicantL, OWNER OR .�
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 Total No. Additional CITY
the permit is for one hundred dollars($100)or less.) PLAN CHECK
I certify that in the performance of the work for which this APPLICANT
permit is issued,I shall not employ any person in any manner
po as to become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS
Total No. Additional
CITY Tel. No.
Date- Applicant Fixed Appliances Not Over 1 HP
NOTICE TO APPLICANT: If, after making this Certificate of PERMIT /
Exemption, you should become subject to the Workers' Range_ Heater_D.W. _ APPLICANT ✓ j
Compensation provisions of the Labor Code, you must forth- Oven —Dryer —W.M.— ADDRESS
with comply with such provisions or this permit shall be Top _ FAU —W.H. —
deemed revoked. Hood _ Fan _Other— CITY ` Tel. No.6?&(a
LICENSED CONTRACTORS DECLARATION Room Air Cond. LICENSE O
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. _ REG.NUM)fElf Class.
(commencing with Section 7000)of Division 3 of the Business DISTRICT N PROCESSED BY a
and Professions Code,and my license is in full force and effect. Power Apparatus 8 Large Appliances d S D . , U
Size&Type HP, KW, KVA, or KVAR r
License 5Nmber Lic.Class Up To 1 Incl. FDRALOOver 1 to 10 Incl. � VALIDATION 0
Contrac Over 10 to 50 Incl. FIN LV
❑ I am exempt under Sec. Over 50 to 100 Inc.' BY n
B.&P.C. for this reason • Over 100 Z
Date: Services, Swbd., MCC&Panelboards 251 Q1 A
0 -200 Amp. Under 600 V
Signature 201 - 1000 Amp. Under 600 V # 0 0 0 0 0 2
❑ Over 1000 Amp. or Over 600 V
Exemption for Reg. Maint. Elect. I o o67.50
SINGLE FAMILY Temp. Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit o o o 6 7,5 0 5
1 hereby affirm that I am exempt from the Contractor's License Additional Sign Branch Circuits
Law for the following reason (Section 7031.5; Business and07.22-86
Professions Code):
❑ I, as owner of the property, will do the work and the Misc. Conduits&Conductors
structure is not intended or offered for sale (Section Other(See Complete Fee Schedule)_ ,
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 issued PERMIT FEE (Sub-Total)
(Sec. 3097, Civ. C.).
PLAN CHECKING FEE
Lender's Name 0 O
PERMIT ISSUING FEE
Lender's Address
I certify that I have read this application and state that the I TOTAL FEE 67 .5-6
above 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 abve-mentioned property for Inspection pu�pcses. SEE REVERSE FOR EXPLANATORY LANGUAGE
Sig
nat a of Permute (\\ \11
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 ELECTRICAL PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS EL 0508 0206210032
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
GAL FEES PAID BUILDI G AD RES :
TR: 5904 LT: 182 6167 SULTANA AV
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917801552
ASSESSOR INFORMAT ON NUMBER: NEAREST CROSS STREET: LONGDEN
5384-006-019 Al PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 596 GRID: H2 LOCALITY: TEMPLE CITY
JB AC UNITS +3-10HP 1.00 AC 19.65
TENANT: TOTAL FEES 47.40 ISSUED ON: PROCESSED BY: PLA Y: EXPIRES ON:
06/21/02 JK 12/18/02
OWNER: TEL. N0: FAL AT�� F �A BYy CODE:
OWNEGINA AND ALICIA ARRIZON (626) 286-1379- _/L
616! SULTANA AV
TEMP 917801552 DESCRIPTION OF WORK
C/O HVAC
APPLICANT: TEL. 0:
CONNOR A/C (626) 286-3157-
4931 ENCINITA AVENUE SPECIAL CONDITIONS:
TEMPLE CITY 91780
CONTRACTOR: EL. N0: APPROVALS DATE INSPECTOR SIGNATURE
CONNOR AIR CONDITIONING (626) 286-3157-
4931 ENCINITA AVE LIC. NO TEMPORARY P E PO
TEMPLE CITY, CA 91780 403735 C2O
ti
UNDERGROUND CONDUIT
ARCHITECT OR ENGINEER: 0: UFER GROUND
LIC. N0: ROUGH CONDUIT
ROUGH R G
MAIN WATER LINE
PLASTIC Y/N METAL Y/N
_ UTILITY COMPANY NOTIFIED
REPORT ID: OPR265 ROUTE TO: BS0508