HomeMy Public PortalAbout4505TEMPLE CITY BLVD_Electrical (2) i WORKERS COMPENSATION DECLARATION% •AaD19DFW3/V APPLICATION FOR ELECTRICAL PERMIT O
y oGfirm that I have a certificate of consent to self ��,
in u e or a certificate of Workers' Compensation Insurance COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
or o certified copy therpof (Sec 3800 Lab C ) _
•i Policy No Company FOR APFl1CANi 70 FILL W !OB J{�J� \'P�`z"�e\6 C+\') �\
❑Certified copy is hereby furnished New Residential Bldgs 8 Pools EACH NO FEE ADDRESS
Certified copy is filed with the county)building inspec- 1 E 2 Family, Sq Ft S = $ LOCALITY
tion department Multi-family Sq Ft NEAREST •n ��
Date Applicant
Residential Swimming Pools WSRSO rJ
_ \\a=
FIRM NAME tt��
CERTIFICATE OF EXEMPTION FROM WORKERS' �7•} g 9 Sw :r �� MAIL -.r•
COMPENSATION INSURANCE Outlets Recsl�._Li M 0 io
' ADDRESS '1�r\\�
(This section need not be completed if the work Involved by Total No First 20 ' D CITY Tom, Tel No q4� �a7
the permit Is for one hundred dollars (5100)or less ) Additional / IOD
I certify that in the performance of the work for which this APLANICCHECK
permit is issued I shall not employ any person in any manner
so as to become subject to the Workers Compensation Laws Lighting Futures First 20 Q AddADDRESS
Additional
Total No � CIN Tel No
Date Applicant
NOTICE TO APPLICANT If after making this Certificate of Fixed Appliances Not Over 1 HP PERMIT
Exemption, you should become subject to the Worker .Range Healer—DW _ APPLICATK7N
Compensation provisions of the Labor Code you must forth Oven :Z 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
LICENSED CONTRACTORS DECLARATION DLICENSE OR
isp _ Room Au Cond RE NUMBER Class
I hereby affirm that I am licensednns
licensed under prosioof Chapter 9
(commencing with Section 7000)of Division 3 of the Business Power Apparatus 8 Large Appliances i DISTRICT NO P ED BY d
and Professions Code,and my license is in full force and effect _ ,.{'
Size 8 T His KW KVA, or KVAR .c-J• D -C�s..i O
License Number tic Class Up to 1 Incl FINAL (..)
Over 1 to 10 Incl DATE t VALIDATION Q
Contractor Date Over 10 to 50 Incl
aFINAL '
I am exempt under Sec Over 50 to 100 Inc BY LU
B BP C for this reason Over 100 d
Date
Services Swbd , MCC 8 Panelboards � , � - Z
0 200 Amp Under 600 V
Signature 201 - 1000 Amp Under 600 V •
❑ Over 1000 Amp or Over 600 V
Exemption for Reg Maint Elect
SINGLE FAMILY Temp Power Pole 8 Appurtenances
HOME OWNER-BUILDER DECLARATION a
1 hereby affirm that I am exempt from the Contractor s License Sign with One Branch Circuit 1 .t
Law for the following reason (Section 7031 5 Business and Additional Sign Branch Circuits -1j- ir�l�,lilj
Professions Code) ,
® I, as owner of the property, will o the work and the r
Misc Conduits&Conductors_ structure is not intended or offered for sole(Section 7044, Other (See Complete Fee Scheduled ► T C I j AL 100 - 00
Business and Profes,iom Code) '
CONSTRUCTION LENDING AGENCY LHEC(i Mi.CIE,
I hereby affirm that there is a construction lending agency for CHANGE .1113
the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) l
(Sec 3097, Civ C )
PLAN CHECKING FEE c
Lender s Nome Q[I[ILI-f1�[Q J, Sf91
PERMIT ISSUING FEE
Lender s Address
I certify that I have read this application and state that the TOTAL FEE
drove mform lion is correct I agree to comply with all County _
ordinances and State jaws regulating Electrical wiring, and
hereby authorize representatives of this County to enter upon -
the ab ve mentioned property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
_ S-S- 9/
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Sigfhotur o wminee - Date