HomeMy Public PortalAbout4509TEMPLE CITY BLVD_Electrical i
j WORKERS COMPENSATION DECLARATION 76AW 10/8N APPLICATION FOR ELECTRICAL PERMIT lnI
I hereby affirm that I have o certificate of consent to self C8' 'I
insure or a certificate of Workers Compensation Insurance, COUNTY OF LOS ANGELES `/�. BUILDING AND SAFETY IUI
oro caoifie- d t J�te>af{bqy Lab C ) /
12Lc Nf��Sys(/-Coom pp6nn a FOR APPLICANT TO FILL IN JOB f, ��
ILIILv�^Jr Certified copy is hereby furmshed �� �F� EACH NO FEE ADDRESS
LGI✓ New Residential Bldgs 8 Pools
Certified copy is filed with the county budding mspec- 1 &2 Family Sq Ft S — F LOCALITY
tion department Multi-family Sq Ft — NEAREST
CROSS ST
Residential Swimming Pools Q
Date,//J—bApplicant'�"^�'+�� OWNER OR
FIRM
CERTIFICATE OF EXEMPTION FROM OMPENSATION INSURANCE WORKERS OutletsRec_Ught_Sw— - ADDRESS RE55
(This Faction need not he completed if the work Involved by First 20 CI�,��s
the permit is for one hundred dollars($100)or less ) Total No Additional
I certify that in the performance of the work for which this PLAN CHECK
Permit is issued, I shall not employ any person in any manner APPLICANT
so os to become subject to the Workers Compensation Laws Lighting Fixtures Fant 20 ADDRESS
Total No , Additional
Date Applicant CITY Tel No
Fixed Appliances Not Over 1 HP
NOTICE TO APPLICANT If after making this Certificate of 1 PERMIT
Exemption you should become subject to the Workers Range_ Heater_D W _ APPLICANT
Compensation provisions of the Labor Code you must forth Oven _ Dryer _ W M — ADDRESSIvhg g-
49-1//
with comply with such provisions or this permit shall be Top _ FAU —W H
deemed revoked Hood _ Fan _Other— CITY ^/ No /0�0
LICENSED CONTRACTORS DECLARATION LICENSE OR
I hereby affirm That I am licensed under provisions of Chapter 9 Disp , Room Air Cond REG NUMBS Class�O
(commencing with Section 7000) of Division 3 of the Business DISTRICT NO PROCE D B�'
and Professions Code and my license is in full farce and effect Power Apparatus 8 Large Appliances
f�j
�fQ ��--,,nn Size 8 Type HP KW KVA or KVAR
License Numb-02A931eK Lic Classes _ Up to 1 Incl FINAL ATE / - k7
Over I to IO Incl _
Conlract� �NT�+�"UOte �e'�✓��� Over 10 to 50 Intl FINAL
! ~�r VALIDATION Q
❑ 1 am exempt under Secri
Over SONO 100 Inc BY r„-. L
B 8P C for this reason Over 100 Z
Date Services Swbd MCC 8 Panelboards ►
0 200 Amp Under 600 V
5°n°ture 201 - 1000 Amp Under 600 V _ O_yys�
❑ Exemption for Reg Mo "Over 1000 Amp or Over 600 V
mt Elect
i
SINGLE FAMILY Temp Power Pole&Appurtenances f11
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor s License Additional Sign Branch Circuits
for the following reason (Section 7031 5 Business and
Professions Code) ;F6 7 Q 2 A
❑ I as owner of the property will do the work and the Mis< Conduits 8 Conductors - - - -
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)- 41#,� s s s - 2 -
7044 Business and Professions Code) 2'-'- 2 0 50
CONSTRUCTION LENDING AGENCY - - -
I hereby affirm that there is a construction lending agency for is ' s 20 5 0 FI
the perfornwnce of the work for which this permit is issued PERMIT FEE (Sub Total) j—
(Sec 3D97 Cw C ) 1 006'-82
PLAN CHECKING FEE -
Lender s Name
PERMIT ISSUING FEE
Lender s Address ,
I certify that I have read this application and state that the TOTAL FEE
above information is correct I agree to comply with all County
ordinances and State jaws regulating Electrical wiring, and
her)"thonze rep�resentatives of this County to enter upon
t olio mnnit no p arty for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE916'
nature o ermia Date