HomeMy Public PortalAbout4522TEMPLE CITY BLVD_Electrical • WORKER SCOMPENSATION
ate of cMUMIAMTION 2DO0,9DP1V„2 9„ APPLICATION FOR ELECTRICAL PERMIT
I hereby.A/hrm t�! f here a certificate of consent to sell insure
• or a certificate of Worker s Compensation Insurance or a certified COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV
copy thereof(Sec 3800 Lab IC) >•Policy No No Company FOR APPLICANT TO RLL IN JOB \
Certified copy is he furnished NO EACH FEE LOCALITY
�1 �J
reby, New Residential Bldgs 6 Pools LOCALITY
❑ , Certdied copy is filed with the county building Inspection 1&2 Family Sq Ft — $ $ `
department Multi lamely,Sq FI — NEAREST
CROSS ST
Dote Applicant Residential Swimming Poole ASSESSOR
MAP BOOK PAGE PARLfL
T CERTIFICATE OF EXEMPTION FROM WORKERSOWNER OR I
COMPENSATION INSURANCE Outlets Rec�Q Ugh Sw FIRM NAME
perms section need not W Fitt 20 completed the work Involved by the Total No '�I AAdditional A4 zz CRESS 7-Z t
permit M for one huntlrotl dollop(31000)or leu)
1 certify that in the performance of the work for which this permit CITY 7We CITY' TO /C�
Is issued I shell not employ any para n in any manneMaso PLAN 1become 9u Ject to he Worker. Comp. .Non L s Ughtng FixturesFus120Total No _}J_ Additwnal ADDRESS
DatealzV Applicant RESIDENTIAL APPLIANCES NOT OVFA 3 HPNOT E TO P LICANT II after m ki ilii rtCITY Tal No
Exemphon you should become subject tO the Worker omOTHER APPLIANCES NOT OVER 3 HP
provisions of the Labor Code PERMIT
p you deemed
forthwith comply with such Power Apparatus A Large Appliances APPLICANT
provleione or this permit shell be deemetl revoked {��,
` LICENSED CONTRACTORS DECLARATION Sue&•Type HP KW KVA or KVAR ADDRESS D 10 P
r pi(/�
I hereby affirm that I em licensed under provisions of Chapter 9 Over 3 m t01nct
(commencing with Section 7000) of Division 3 of the Business and CITY t TO No 9969
Professions Code and my license is in full force and effect Over 10 to 50 Ind Al^ Over fiO to 100Incl gEUNNU SER �'" �� pan C! d
License Number ` Lic Class v /0 - - 'Over
100
DISTRICT rq P v 0
Servicea Swbd MOC&Panelboerds J.O(J Q
Contractor Date 0 399 Amp Under 800 V R"L
DAM F_
F1_ I am exempt u .,Sec 400 IODO Amp Under BOO V 5_27-93 VALIDATION W
Over 1000 Amp or Over 600 V _
B&P C for this season By - -/
BRANCH CIRCUIT FEES F � Z
Date 15A or 20A 120V Lighting or Receipt
1 To 10 Branch Circuit
Signature 11 TO 40 Branch Circuit
❑
Exemption for Reg Meinl Elect1
- 154.20A 208V To Ughbrig Mone Branch
3r GCs Ib
SINGLE FAMILY Temp Power Pole&Appurtenances
HOME OWNER BUILDER DECLARATION
I hereby affirm that I em exempt from the Contractors License Lew Sign with One Branch Circuit a 7
for the fallowing reason (Section 7031 5 Business and Professions Additional Sign Branch Circuit _ _ ACCT a _
Code) .A
❑ Misc Conduits&Conductors - 7 iQ5.45
I as owner of the property will do the work and the structure _
is not intended or offered for Bele (Section 7044 Business Other(See Complete Fee Schedule)— -
and Professions cads) _ __ _ 1 ITEM5
CONSTRUCTION LENDING AGENCY ° _ TOTAL 105.45 c
I hereby affirm that there is a construction lending agency for the
performancer• 105.45
of the work for which this permit is issued (Sec 3097, PERMIT FEE (Sub Total) C
'� K
Civ C)
CWNE quo
PLAN CHECKING FEE _ _
Lender a Name
Lenders Address
PERMIT ISSUING FEE ZS X01 4/27/93
6 -
1 certify that I he"read this application and under penalty of purlury stale TOTAL FEE
That the above Information t correct I agree to compM 9'3M 1ty DAall County _ _ _ _ AM 8.26
ordinances and Slate laws regulating Electrical wring and hereby,euthonze
reprevejItairvatiolthmCouinty rater ion the abowf-mentgned property
for ion p Daae SEE REVERSE FOR EXPLANATORY LANGUAGE
910NA a DATE