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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