HomeMy Public PortalAbout4442TEMPLE CITY BLVD_Electrical (2) WORKERS COMPENSATION DECLARATION 10n81
YEAPPLICATION FOR ELECTRICAL PERMIT {�
I retry dve ttrtm that I haa certificate of consent to self insure CE CE 806 8oe0 �f
or a certificate of Workers Compensation Insurance or a candied COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof (Sec 3800 Lab C)
Policy No CompanyFOR APPUCANT TO FILL IN CRESS 1, (7 /
❑ Certified copy is hereby furnished New Residential Bldgs 8 Pools EACH NO FEE f—
❑ Certified copy is filed with the county building IMpecuon 1 & 2-Family Sq Ft $ — $ LOCALRY�'
departrrent Multi-family Sq Ft NEAREST
CROSS ST
Date Applicant Resdental Svnmmlrig Pools ONNER OR
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS Outlets Rec_Light _ Sw �
COMPENSATION INSURANCE - ADDRESS
First 20 CITU Tel No
(This section need not be completed d the work ImoNed by the Total No Additional 7
permit is for ane hundred dollere($100)or lase) I=tul CHECK
1 certlty that in the performance of the work for which this permit
is tasted I shall not employ any person In any rtanrer so as to APPUCANT
become sublect,lo the Workers Compensation Leve Lighting Fixtures First 20 ADDRESS
Total No Additional CRY ' r Tel No
Data Applicant
NOTICE TO APPLICANT If attar making this Certificate Applances Not Owr 1 HP PERMIT
Exemption
of -
Exemption you should become subject to the Workers Compensation Range— Heater— DW _ AST
pros cns of the Labor Code you must forthrmh comply wth such Own _ Dryer_ W M _ ADDRESS
prmnsons or this permit shall be deemed rawked Top — FAU _ WH
LICENSED CONTRACTORS DECLARATION CITU _ Tel No
Hood Fan Other—
I hereby affirm that I am licensed under pmvisiore of Chapter 9LICENSE OR
(commencing with Sect7000) of'Dlvsion 3 of the Busmess and Disp Room fur Cond REG NUMBER �°
Section
Professions Code and my license is in full force and effect Power Apparatus 8 Large Appliances DISTRICT NO PROCESSED BY _
Size& Type HP KW KVA or KVAR
License Number Lie Class Up to 1 IrxJ FINAL
Contrecta Date - Owr Ito 101rict DATE �-17-1
Over 10 to 50 Incl FINAL
MOATIQ
I ❑ I am exempt under Sec Over 50 to 100 Inc BY - W
B&PC for this reason Owr 100
Services Swbd MCC 8 Panelboards Z
Date 0-200 Amp Under 600 V
Signature 201 - 1000 Amp Under 600 V '
Over 1000 Amp or Over 600 V
ElExemption for Reg Maint Elect
SINGLE FAMILY Temp Power Pole& Appurtenances 2
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
C.'..T
I hereby affirm that I am exempt from the Contractor a license Lew
for the following reason (Section en
on 7031 5re d Professions cu
Additional Sign Branch Circuits
Code) 3307 31.00
lit! ds D nen ovT f the property w lI do the and the structure Mac Conduits& Conductors 1 IT J
Is not Intended or offered for sale (Section 7044 Busineee Other(See Complete Fee Schedule) _
and Pmfessicns Code) TOTAL J 1. 00
CONSTRUCTION LENDING AGENCY - CASH 31.00
1 hereby affirm that there is a construction lending agency for the
performance of the v rk for which this permit is Issued(Sec 3087 PERMfT FEE (Sub-Total) - — CHANGE .OTI
Cry C)
Lenders Name PLAN CHECKING FEE /� — _ 0000-01001 10/19/90
PERMIT ISSUING FEE 3406 1 AM 7:5+
Lenders s —
1 cercertifyththat
et I haw reatl this,application and elate that the shove TOTAL FEE
mfornaton Is correct I agree to comply with all County ordmences
and State laws regulating Electrical winng and hereby authorize _
representatives of this County to enter upon the above-mentioned
property for inspection purpose'// 9 _ r
'/ Q //A SEE REVERSE FOR EXPLANATORY LANGUAGE
Sgnatumof Permittee Data