HomeMy Public PortalAbout4810TEMPLE CITY BLVD_Electrical WORKERS'COMPENSATION DECLARATION S
CE 806G 12 80) APPLICATION FOR ELECTRICAL PERMIT
CE 808j
� r
I hereby affirm that I have certificateof convent to self COUNTY OF LOS ANGELES /� BUILDING ANb SAFETY
insure or a certificate of Workers'
rs'Compenompen sation Insurance,or
a certified copy thereof(Sec 3800 Lab C)
Company FOO APPLICANT TO FILL IN JOB
Policy No ADDRESS
New Residential Bldgs &Pools EACH NO FEE I O `ta^
❑ Certified copy is hereby furnished 1 &2 Family,Sq Ft $ — S LOCALITY
Multi-familV Sq Ft
❑ Certified copy ts filed wit t count u ding inspection CROSS ST
department Residential Swimming Pools OWNER OR
FIRM NAME
Datev pphce Outlets Rec—Light Sw _ MAIL k,
first 20 ADDRESS rC.
CERTIFICATE OF EXEMPTION FROM RKERS Towl'No Additional CIT Tal'No }
COMPENSATION INSUR kNC
PLAN CHECK rd
i (This section need not be completed If the work Involved APPLICANT Q
Lighting Fixtures First 20 v
by the permit a for one hundred dollars ($100) or lees) Additional ADDRESS ¢O
1 certifythat in the Total No
performance of the work for which neer Fixed Appliances Not Over 1 HP CITY Tal No F
permit n issued, I shell not employ any person in any manner PERMIT �n W
so as to become subject to the Workers' Compensation Laws Range_ Heater_D W _ APP (CANTn �— Ui. I✓ a
Oven _ Dryer_W M _ ADDRESS X W
Date Applicant 1
i Top — FAU _W H �n �O n Z_
Hood _ Fan _Other_ CIT 4 r-x_. Tel No ��okf
NOTICE TO APPLICANT If after making this Certificate of Disp _ Room Air Cond_ LICENS R _ l
Exemption, you should become subject to the Workers IDA
EG NUMBER Class
Compensation provisions of the Labor Code, you must forth Power Apparatus& large Appliances ISTRICT NO PROCESSED BY
with comply with such provisions or this permit shat be Size&Type HP KW KVA,or KVA d d
deemed revoked - o
Up to 1 Incl
INAL
Over 1 to 10 Incl TE LICENSED CONTRACTORS DECLARATION Over 10 to 50 InclVALIDATION
I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc INAL9 (commencing with Section 7000)of Division 3 of the Busi Over 100V _
nese and Professions Code and my license is in full force and -
effect Services
License Number Lic Class _ 0 200 Amp Under 600 V
201 1000 Amp Under 600 V
Contractor Date Over 1000 Amp or Over 600 V
HOME OWNER BUILDER DECLARATION Temp Power Pole&Appurtenances
1 hereby affirm that 1 am exempt from the Contractor's Sign with One Branch Circuit
License Law for the following reason (Section 7031 5 Busi Additional Sign Branch Circuits
ness and Professions Code) i' \
Mise Conduits&Conduetois
❑ 1, as owner of the property will twork and the Other (See Complete Fee Schedule)— \ ii ��5 3 0.4 A
structure u not intended or offered
for for sale (Section
7044, Business and Professions Code) .. - — ----#: e • • • 2
CONSTRUCTION LENDING AOLNCY ' q
I hereby affirm that there is a construction lending agency N e - 2 3 5 0
for the performance of the work for which this permit is PERMIT FEE (Sub Total)
Sec 3097 Civ C
issued
( ) • • • 2350
Lender's Name PLAN CHECKING FEE (One-Fourth Permit Feel ' `
Lender's Address PERMIT ISSUING FEE 0a02-82
t
I certify that 1 have read this application and state that the TOTAL FEE
above information is correct 1 agree to comply with all County t ..
ordinances and Siete egulating Electrical wiring and
y authorize rep ntaM1 n of this County to enter upon ' r.
he a ove mentioned ropert r inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
r----'SIggr(aturq,r,Af Permittee Date t