HomeMy Public PortalAbout4830TEMPLE CITY BLVD_Electrical WORKERS COMPENSATION DECLARATION 76F669 10/81 APPLICATION FOR ELECTRICAL PERMIT
I fieoe�y affum that I have a centfrate of consent to self CE�'
insure or a ceriihcate of Wprkers Compensation Insurance COUNTY OF LOS ANGELES BUILDING AND SAFETY
vo certified copy thereof (Sec 3800 Lab C ) o
Policy No Company FOR APPLICANT TO FILL IN
E55 g3 Q T G 81.J
Certified copy is hereby furnished New Residential Bldgs 8 Pools EACH NO FEE
❑ • Certified copy is filed with the county building mspec- 18 2-Family Sq Ft f — $ LOCALITY T (�
tion department t Multi-family Sq Ft — NEAREST
CROSS ST
Res.dent�ol Swimming Pools '' rt
Dote Applicant , OWNER OR 1`r ClJ ley G' VELI c�S C.L{
ti / _ FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS Outlets Rec Light Sw - - MAIL �` a(ud
COMPENSATION INSURANCE W ADDRESS 4830 T
(This section need not be completed if the work Involved by - First 20 +- -
the permit Is for one hundred dollars ($100)or leu j Total No� Additional - CIN („ Tel No U46-2037
RAN CHECK
certify that m the performance a the work for y which manner
APPLICANT �j CL,1,,,_�
permit is issued I shall not employ any person in any manner
so as to become subject to the Workers Compensation Laws Lighting Fixtures Fust 20 s ADDRESS
v cnAdd
itional
Date--I I27Ig6 Applicant foft
QJ� it i' ...•� Total No CITY Tel No
IFixed
NOTICE TO APPLICANT If after making this Certificate of Appliances Not Over 1 HP PERMIT
Exemption you should become subject to the Workers Range_ Heater_D W _ APPLICANT
Compensation provisions of the Labor Code you must forth- Oven _ Dryer _W M — ADDRESS
with comply with such provisions or this permit shall be T _ FAU —W H —
deemed revoked Hood _ Fon _Other_ CITY Tel No
LICENSED CONTRACTORS DECLARATION UCENSE OR
I hereby affirm shot I am licensed under provisions of Chapter 9 Dtsp Room Air Cond REG NUMBER Class }
(commencing with Section 7000) of Division 3 of the Business DISTRICT NO PROCE BY d
and Professions Code and my license is in full face and effect Power Apparatus 8 Large Appliances �j U
Size 8 Type HP KW KVA, or KVAR J f 0
License Number Lic ClassUp to 1 Incl FIN
DA O
�y
Over 1 to 10 Incl DATE /V "' 6 VA ATION h-
Contractor Date Over 10 to 50 Incl 0
❑ a
I am exempt under Sec Over 50 to 100 Inc BY �i 9i i N
B 8P C for this reason Over 100 ( e • 2 2 5 0 Z
Date Services Swbd, MCC d Ponelboards ►
0 -200 Amp Under 600 V
Signature 201 1000 Amp Under 600 V e e * 22505
❑
Exemption for Reg MaOver 1000 Amp or Over 600 V
mt Elect
SINGLE FAMILY Tem Power Pole 8 U 1'2 3 1 8 6
Temp Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I herebyaffirm that I am exempt from the Contractor s License Additional Sign Branch Circuits '
Law for the following reason (Section 7031 5 Business and
Professions Code)
I as owner of the property will do the work and the M,sc Conduits 8 Conductors PIP is not intended or offered for sole (Section Other(See Complete Fee Schedule)_ '
704 Business and Professions Code)
CONSTRUCTION LENDING AGENCY
hereby affirm that there is a construction lending agency for
Sthe performance of the work for which this permit is issued PERMIT FEE (Sub-Total) v D
(Sec 3097 Civ C )
t
NLC.uLAfE VEL-.tCeSLIL4 PLAN CHECKING FEE
Lander theme
40.30 -I-e.—c:!+ C:I Uhf PERMIT ISSUING FEE
Lenders Address ` r
I certify that I hove read this application and t� TOTAL FEE h/
above mforma6on is correct I agree to comply with all County
ordinances and State jaws regulating Electrical wring, and -
hereby authorize representatives of this County to enter upon
the above mentioned property for inspection purposes
ZI SEE REVERSE FOR EXPLANATORY LANGUAGE
CL c��
Signature of Permittee Dale ,