HomeMy Public PortalAbout4510TEMPLE CITY BLVD_Electrical (2) wORKERS'COMPENSAT[ONDECLARATION CE 806 APPLICATION FOR ELECTRICAL PERMIT
76A663 (2 80)
I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY
msurl, or a certificate of Workers'Compensation Insurance,or
e ceru5ed copy thereof(Sec 3800, Lab C)
FOR APPLICANT TO FILL IN JOB
Policy No Company New Residential Bldgs &Poole EACH INO I FEE ADDRESS /O /
❑ Certified copy is hereby furnished 1 &2 Famdy,Sci Ft 9 — S LOCALITY
❑
Certified co y e p Multi family Sq Ft
copy n filed with the count building inspection Residential Swimming Pools CROSS 5
department OWNER OR
FIRM NAME
Pate Applicant Outlets Rec_Light_Sw _/ AAD First 20
CERTIFICATE OF EXEMPTION FROM WORKERS Total No Additional
CITY
/ COMPENSATION INSURANCE PLAN HEC TN No d
(Thu section need not be Com kited it the wink smolved APPLICANT 8
by the permit u for one It= dollua (5100) or teas) Lighting Fixtures First 20 ADDRESS
Total No Additional 2
I certify that in the perform nL
he work for which this CITY Tel No U
Fixed Appliances Not Over 1 HP
permit is issued, I shell note py person in any me er PERMIT
as t ecome subject totes' C e non Range— Heater—D W App ICAN W
,r ��(J/� V Oven _ Dryer_W M ADDR �Y Z
/ Applicant i Top _ FAU _W H
Hood _ Fen _Other_ CI V n l �/4r at N
TIC TO PLICANT If, after making this Certiflc to of Dain _ Room Air Cond` SE OR
xemp on, you should become subject to the'Workers' RE NUMB Clap ,CJ
Compensation provisions of the Labor Code, you must forth Power Apparatus&large Appliances DISTRICT NO PROCE ED BV r
with comply with such provisions or this permit shell be F
deemed revoked Size&Type HP,KW,KVA or KVA /—/ O y
_ Up t0 1 Incl FINAL O 0
Over 1 to t0lncl
�
LICENSED CONTRACTORS DECLARATION DATE P'¢'8a VALIDATION
Over 10 to 50 Incl
I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc
9 (commencing with Section 7000)of Division 3 of the Busi Over 100 BY
nep and Professions, Code, and my license is in full force and
effect Services
License Nu'—/y`�I'JTG/�[i Lic Lep /90� 0 200 Amp Under 600 V
\ 201 1000 Amp Under 600 V q
Con ' , Date Over 1 DDO Amp or Over 600 V
HOME OWNER BUILDE D LAR TION Temp Power Pole&Appurtenances
I hereby affirm that I am exempt from the Contractor's Sign with One Branch Circuit
License Law for the following reason (Section 7031 S Bust Additional Sign Branch Circuits
ness and Professions Code) - 1 3,1 5 A
Mise Conduits&Conductors +
❑ 1, as owner of the property, will do the work and the Other (See Complete Fee Schedule)— • • e • • 2
structure Is not intended or offered for sale (Section
7044, Business and Professions Code) 2 • • 1950
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency • • • 1 950P!
for the performance of the work for which this permit is PERMIT FEE (Sub-Total)
issued(Sec 3097,Civ C) /.1 6 '
Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee) 1 T-$0
L 1
r
Lender's Address '� PERMIT ISSUING FEE
v
at
I have reed this application and state that the + TOTAL FEE
I certtkaove f motion u correct t agree to comply vnth all County
a
nd State lAteinng Electrical Winn , endnzerepreseth Conuotied pris n EE REVERSE FOREXPLANATORY LANGUAGE
/gyp
Signature of Perini ae to
c