HomeMy Public PortalAbout4509TEMPLE CITY BLVD_Electrical (2) WORKERS COMPENSATION DECLARA]ION 76A663 I0,87 • APPLICATION FOR ELECTRICAL PERMIT
I hereby offirm that I have a certificate of consent to self CE War
insure or a certificate of Workers Compensation tnsurayn/.ce/' COUNTY OF LOS ANGELES `T e BUILDING AND SAFETY
or a cgrtLfgpy.tflp gp�r�000 6 C ) /s/ v v
Y N �/'j�/�(C7om(pa/ny FOR APPLICANT TO FILL M JOB
ADDRESS J ,
Certified copy is hereby furnished New Residential Bldgs 8 Pools EACH NO FEE
Certified copy is bled with the county budding mspec- 1 8 2 Family, Sq Ft
: — : LovulTrT �.
hon deportment Multi-family Sq Ft — NEARESTCROSS 57
Dot er-cc/Jf_L-�1=App ice� r�/£,� C Residential Swimming Pools OWNER OR
--x-0-r✓" rr�s FIRM NAME eo
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets Re�Light�Swd.L? MAIL
COMPENSATION INSURANCE First 20 Cit 2W
_ ADDRESS
(This sectloa need not be completed IF the vrork Involved by / CITY e
Me permit is for,ono hundred dollars(f100)or less ) Total NoL Additional ' rJ C J � '
PLTN OiEO
I certify that in the performance of the work for which this APPLICANT
permit is issued,1 shall not employ any person in any manner
so as to become subject to the Workers Compensation Laws Lighting Fixtures 99 First 20 4I 1 C /'- ADDRESS
Total No Additional r I CITY Tel No
Date Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT If after making this Certificate of APPLE LG G'
Exemption you should become subject to the Workers Range_ Heater_D W
Compensation provisions of the Labor Code you must forth Oven — DryerT W M 2 ADDRESS
with comply with such provisions or this permit shall be To _ FAU 2iWH H
deemed revoked I rHood Fon —Other_ CITY N
LICENSED CONTRACTORS _RACTORS DECLARATION Disp _ Room Air Cond 4 C LICENSE OR R"37-5,
Class
(commencing with Section 7000) of Division 3 of the Business DISTRICT NO PROLE BV
and Professions Code and my license is in full force and effect Power Apparatus 8 Large Appliances l' _ 6
J, 7!� ,a �,( Size 8 Type HP, KW KVA, or KVAR 7 (> O
License Numbe J�✓� Lemic Class
_e_LLL Up to I Incl - FINAL / V
c`4IGI�GfP S/nr+te Over 1 to lO Incl DAA
ContractI VALIDATION 0
f Over 10 to 50 Incl FINAL \ 10
I am exempt under Sec Over 50 to 100 Inc BY ��•.. _ r1sr
B 8P C for this reason Over 100 H
Services Swbd , MCC 8 Pana boards 11110. Y 2
Date 0 -200 Amp Under 600 V 'Ue 'T /10
Signature 201 1000 Amp Under 600 V' - d '
❑
Exemption fOver 1000 Amp or Over 600 V
a Reg Mamt Elect
SINGLE FAMILY Temp Power Pole 8 Appurtenances
HOME OWNER BUILDER DECLARATION Sign with One Branch Circuit ;9 7 5 a 5 q
I hereby affirm that 1 am exempt from the Contractor s License Additional Sign Branch Circuits _
Law for the following reason (Section 7031 5 Business and Ti • °t•t• ° 2
Professions Code)
M,sc Conduits d Conductors 2 - 21 ,1 10
1 as owner of the property, will do the work and the
structure :s not intended or offered for sole (Section Other (Sea Complete Fee Schedule)_
7044 Buvo
non and Professions Code) ► ° o ? ) 1 11 0
CONSTRUCTION LENDING AGENCY 8 2
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) 0 1G -
(Sec 3097 Civ C )
PLAN CHECKING FEE
Lender s Name l —
PERMIT ISSUING FEE /
Lender s Address
I certify that I have read this application and state that the TOTAL FEE
above mfor hon is correct I agree to comply with all County
oboe o Stale lows regulating comply
w wising and
her Guth iz s es of this County to enter upon
th ve aired property r inspection purposes ) SEE REVERSE FOR EXPLANATORY LANGUAGE -
Signature of Permihee Dote