HomeMy Public PortalAbout4830TEMPLE CITY BLVD_Electrical (2) WORKERS COMPENSATION DECLARATION , t, 76A663 ,D,BI . APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that have a certificate of conynt ty serf CE-806G -
insure ora certificate of Workers Compen3ahon Inlur- ca, _ COUNTY OF LOS ANGELES BUILDING AND SAFETY
or o certified copy thereof (Sec 3800 Lab C )
Policy No Company FOR APPLIUNT TO RLL IN JOB - (�ee
Certified co is hereby furnished EACH NO FEE ADDRESS 743o T G l3hal
PY Y New Residential Bldgs 8 Pools
❑ Certified copy is filed with the county building inspec 18 2 Family Sq Ft 450 S — S LOCALITY T-ew CI
non department Multi family Sq Ft —
cRossST {-Owen k-zu5q
Residential Swimming Pools OWNER OR
Dole Applicant j FIRM NAME W,CULAIE IrEL/ CE54
CERTIFICATE OF EXEMPTION FROM WORKERS' A
Outlets Rec I�LightSw 9 '- MAIL SQ
s'L
COMPENSATION INSURANCE ADDRESS
Total No--z ^Q
at
(This section need not be completed If the work Inwlvod by 2 dd ZO -
the permit is for one hundred dollars ($100)or lass ) ( /— ddmonal CITY Tel No -2p3
• RAN CHECK
I certify that in the performance of the work for which thisPRICAM
permit is issued I shall not employ any person in any manner ,
so as to become subject to the Workers'Compensation Laws I Lighting Fixtures First 20 ADDRESS
Ip 11
4 \ .V Total No I I Additional
Dote T Applicantddd""'^^^5 �^ � CITY Tel No
NOTICE TO APPLICANT If after making this Certificate of '� Fixed 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 Top — FAU —W H12
deemed revoked i Hood _ Fan Other_ CITY Tel No
LICENSED CONTRACTORS DECLARATION LICENSE OR
I hereby affirm that I am licensed under provisions of Chapter 9 Dep _ Room Au Cond REG NUMBER Clan
(commencing with Section 7000) of Division 3 of the Business Power Apparatus 8 Large Appliances DISTRICT NO PROCESSED BY
and Professions Code and my license is in full force and effect
Size 8 Type HP KW KVA or KVAR CO
License Number Lic Class _ V
t Up to I Intl FINAL
t Over 1 to 10 Incl DATE � VALIDATION ad
Contractor Dote T Over 10 to 50 Incl FINAL / V
• ❑ I am exempt under Sec j Over 50 to 100 Inc BY
B 8P C for this reason Over 100 in
Dote ; Services Swbd , MCC 8 Ponelboards ► _
l 0 200 Amp Under 600 V
Signature 201 1000 Amp Under 600 V
❑ Exemption far Reg Mont Elect Over 1000 Amp or Over 600 V `
3 0 8 Q 5 A
SINGLE FAMILY '
HOME OWNER BUILDER DECLARATION Temp Power Pole 8 Appurtenances # is 2
a a a a
Sign with One Branch Circuit
hereby affirm that I g r exempt from the Contractor's ss License s Additional Sign Branch Circuits t
Law for the following reason (Section 7031 5 Business and g { • • 6 2-2 5
Professions Code) ,
® I, as owner of the property will do the work and the Misc Conduits 8 Conductors • • a 6 2 2 5 5
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ ► - I Q 0 1 '8 a
7044 Business and Professions Code)
CONSTRUCTION LENDING AGENCY
I hereby affirm that there iso construction lending agency for '
the performance of the work for which this permit is issued PERMIT FEE - (Sub-Total)
(Sec 3097, Civ C )
1 PIAN CHECKING FEE _
Lender s Name I i -
PERMIT ISSUING FEE O
Lenders Address
I certify that I have read this application and state that the . TOTAL FEE
above information is correct I agree to comply with
all County
ordinances and State laws regulating Electrical wiring, and
hereby authorize representatives of this County to enter upon (�the; bone mentioned property for inspection purposes t
o to
/{ ' 8� ) SEE REVERSE FOR EXPLANATORY LANGUAGE
i 61
t Signature of Permatee Dote
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