HomeMy Public PortalAbout5005TEMPLE CITY BLVD_Electrical (2) 7 � �
/ WORKERS COMPENSATION
cateofDECLARATION
once CE 063 ,a,B, APPLICATION FOR ELECTRICAL PERMIT
rl hereby affirm that I have a certificate of consent to self �BO6O
insure or o certificate of Workers' Compensation Insurance COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified/cCopy thereof (Sec 3800 Lab )
Policy Nob W7'ampany FOR APPLICANT TO FILL IN JOB ADDRE55 O
Certified copy is hereby furnished New Residential Bldgs 8 Pools EACH NO FEE
V 01YZI, At ON
19 Certified copy is filed with the county building inspec 1 8 2-Family Sq Ft $ — $ LOCALITY lefit
Gi
tion department Multi-family Sq Ft — NEAREST
2O
C., m Residential Swimming Pools CROSS ST
EL
Dote '45 Applicant )Un FIRM OWNER,0R
ME
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE Outlets Rec_Light_SwFint 20 MAILADDRESS
(This sectiermit I nod nal bo tied dotedlga If Ilio work Invess ) d by Total No Additional CITY Tel No 6-Do L
the permit Is for ono hundred dollen ($100)or loss j
RAN CHECK
I comfy that m the performance of the work for which this APPLICANT
permit is issued I shall not employ any person in any manner
so as to become subject to the Workers Compensation Laws Lighting Fixtures First 20 ADDRESS
Total No Additional
CITY Tel No
Date Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT If, making this Certificate of C
Exemption, you should become subject to the Workers Range_ Heater_D W — APPLICANT_ . . I
Compensation provisions of the Labor Code you must forth- Oven _ Dryer W M _ ADDRESS D 0 J
with comply with such provisions or this permit shall be Top _ _ FAU W H
deemed revoked CITY Tel No
LICENSED CONTRACTORS DECLARATION Hood _ Fan _ Other—
Disp _ Room Air Cond LKE Class r�rr��
I hereby affirm with
am licensed under provisions3ofof Chapter 9 REG NUMBER O L.I
(commencing with Section y tic of Division fu 3 of the Business Power Apparatus 8 Large Appliances DISTRICT NO PROCE Y r
and Professions Code and my license is�n full force and effect �
//�s Size 8 Type HP KW, KVA or KVAR -57
License Number Uc Class .y.$ - U
U to I Incl FINAL 'fin �
r t g_f 6 4� Over 1 to 10 Incl DAA "�l�J S/ VALIDATION Q
Contractor ate Over 10 to 50 Incl
❑ I am exempt under Sec FIN
P Over 50 to 100 Inc BY W
B 8P C for this reason Over 100 C Z
Date vices Swbd MCC 8 Panelboords 11011. sL.ss3 -
.�- 200 Amp Under 600 V
Signature 201 - 1000 Amp Under 600 V
❑ Exemption for Reg Momr Elect Over 1000 Amp or Over 600 V .127 3 0 A
SINGLE FAMILY Tamp Power Pole 8 Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit # is is s is s 2
1 hereby affirm that I am exempt from the Contractor s License
Law for the following reason (Section 7031 5, Business and Additional Sign Branch Circuits ( o • 3 6 0 0
Professions Code)
❑ I as owner of the property will do the work and the Misc Conduits&Conductors • • - 36005
structure is not intended or offered for sole (Section Other (See Complete Fee Schedule)— ►
7044, Business and Professions Code) p 81 6-85
CONSTRUCTION LENDING AGENCY _ -
s I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued PERMIT FEE (Sub Total)
(Sec 3097 Cry C )
PLAN CHECKING FEE
Lender s Name
PERMIT ISSUING FEE
Lender s Address
4ceo, that I have read this application and state that the TOTAL FEE - 3
to comply with all County
ng Electrical wiring and
this County to enter uponmentioned rty for inspection purposes
a.0'SiREVERSE FOR EXPLANATORY LANGUAGE
gnature of Perm,nee ate`