HomeMy Public PortalAbout5002TEMPLE CITY BLVD_Electrical (2) D-0019
WORKER I haveCOMPENSATION Df consent DECLARATION 2,411W DPW(12 e1) APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to gall insure 74A883
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 C) -�
r
Policy No Company FOR APPLICANT TO FILL IN JOB
ADDRESS OZ
Certified copy is hereby furnished New Residential Bldgs 8 Pods NO " EACH FEE LOCALITY❑ — $ S
Certified copy is filed with the county building Inspection 1 8 2 Family Sq Ft NEAREST
department I I I Multi famity Sq Ft — CROSS ST '
Date Applicant Residential Swimming Paola ASSESSOR
MAP BOOK PApE PARCEL
'CERTIFICATE OF EXEMPTION FROM WORKERS Outlets Rec _Light Sw OWNER OR e
COMPENSATION INSURANCE RPM NAME JaAm
(Thle'eectlon need not be completed If the work Involved by the Firm 20 A�OogE66 A
permit Is for one hundred dollars(5100)or lees) Total No Additional 5"&VZ wo
I certify that in the performance of the work for which this permit _ CITY I Tel No
is Issued I shall not employ any person in any manner so as to • r
CHECK
become subject to the Workers Compensation Laws Lighting Fimm First 20 AI PRU
Total No Addibonal
ADDRESS
DateApplicant RESIDENTIAL APPOANCES NOT OVER 3 HP
NOTICE TO APPLICANT It after making this Certificate of CITY — TN No
Exemption you should become subject to the Workers Compensation OTHER APPLIANCES NOT OVER 3 HP PERMIT PEMrt
provisions of the Labor Code, you must forthwith comply with such power Apparatus&Large Appliances PE -
provisions or this permit shall be deemed revoked R
' LICENSED CONTRACTORS DECLARATION Sus d Type HP KW KVA or KVAR ' ADDRESS
I hereby affirm that I em licensed under provisions of Chapter 9 Over 3 to 10 Ind
(commencing with Section 7000) of Division 3 of the Business and CITY Tia No
Professions Code and my license is in full force and effect Over 10 to 50 Incl
Over 50 to 100 Incl REG UCNUMBER C� a
License Number Uc Close
Over 100 DISTRICT NO PROCESS V O
U
- Services Swbd MCC 8 Penelb5-08oarde Q
Contractor Date 0 399 Amp Under 600 V DAM
Q
❑ I am exempt under Sec 400 1000 Amp Under 800 V �- ZJ VALIDATION V
Over 1000 Amp or Over 600 V Ftrvlll LU
B 8P C for this reason Q.
BRANCH CIRCUIT FEES Br
Date 15A or A V Lighting or Recept O Z
1 To 10 Branch Circuits
Signature Z'y o 40 Branch Circuits
P{IV 41 Or More Branch Circwts
❑ Exemption for Reg Maim Elect 15A 20A 20BV To 2T7V Lighting Br Cucuila r '
SINGLE FAMILY Temp Power Pole d Appurtenances -
HOME OWNER BUILDER DECLARATION Sign with One Branch Circuit ACCT.4
I hereby affirm that I am exempt from the Contractors License Law _
for the following reason (Section 7031 5 Business and Professions Additional Sign Branch Clrcuils 3307 41.70
Code)
I ee owner of the property will do the work and the structure
Mlsc Conduits a Conductors - 1 ITOS
is not intended or offered for sale (Section 7044 Business Omer(See Complete Fee Schedule) TOTAL 41. 70
Iola
and Professions Code) - 41.70
CONSTRUCTION LENDING AGENCY ICK7�
I hereby affirm that there is a construction lending agency for the VTptl1vG .00
performance of the work for which this permit is issued (Sec 3097 PERMIT FEE (Sub Total)
Civ C)
t
PLAN CHECKING FEE 0000-0001 2/24/93
Lenders Name "
PERMIT ISSUING FEE p,3,09 1 AM 9:40
Lender a Address - '
I cemty that I have read this applicabon and under penalty of purlury state TOTAL FEE / 7
that the above Information is correct I agree to comply with all County +
ordinances and State laws regulating Elecmcel wrong and hereby euthorao
representatives of this Cau to enter upon the above mentioned property
for inapec rp SEE REVERSE FOR EXPLANATORY LANGUAGE
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