HomeMy Public PortalAbout5011TEMPLE CITY BLVD_Electrical (2) WORKERS COMPENSATION DECLARATION 7eAe03 APPLICATION FOR ELECTRICAL PERMIT {�
•A hereby �i!m that I have a certdgate of conself insure to reure CE eOaO I--I
or a certificate of Workers Compensation Insurance or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof(Sec 3800 Lab C)
Policy No Com FOR APPLICANT TO FILL IN r- JOB
Pant �O
❑ Cerhfled copy m hereby furnished EACH NO FEE ADDRESS
Naw Resdenhel Bldgs 8 Pods
❑ " ecopy m,filed with the ocunty buildingvrepection
1 8 2-Family SQ Ft S — $ LOCALITY
department
ent Mutts-iemily Sq Ft Cos 87 I.—
Date Applicant Residential Swimming Pools ` - - OWNER Oft
n FAM
NAME I1 y�
ez
WORKERS MLCERTIFICATE OF EXEMPTION FROM Outlets RealLight%qS �i
COMPENSATION INSURANCE
ADDRESS
(This section need not be completed if the work Imofved by the First 20
permit Is far one hundred dollars(S 100)or law) Total No Additional CITY Tel No _
I certify that in the performance of the work for whch this permit PLAN CHECK
is issued, I shall not employ any pawn in any manner x Pf to r AV
become subject to theWorkersWorkers Cornpensatxln Laws // Lighting Fixtures First 20 ADDRESS
Date '� Appincan m�kw�_ Total No _'• Addnaval CITY Tel No
NOTICE TO APPUCANT II of ung m rtdicate of Fixed Apphance9 Not Over 1 HP PE6N1fr
Exemphon you should hecorrle suhjec to the Abdx ers Compenseton Range— Heater— DW _ APPLIGIJr
r prowaols of the Labor Coda you must fortln:nth'comply with such O1 _ Dryer _ WM — ADDRESS
prevmiorls or this permit shall be deemed revoked Top — FAU _ WH
CITY Tel NoLICENSED CONTRACTORS DECLARATION Hood — Fan V_ Other_
I hereby affirm that I am licensed under prevmions of Chapter gasp Nr Cod LICENSE OR
Room CI®a
(commencing with Section 7000) of Dwxm 3 of the Buanes r and REG NUMBER
Profesaorm Code and city'license is in full force and effect Power Apparatus 8 Large Apelmnoes DISTRICr NO TT PROCESSED
Sae It Type HP KW KVA or KVAR
License Number.Lc Class Up to 1 Incl FINAL /
Over 1 to 10 Incl DATE
Contractor Date '� VALIDATIO 00
Over 10 to 50 hid FI F
❑ I em exempt under Sec Over 50 to 1 G Inc F]
BBPC for this reason
Over 100
Services Swbd MCC 6 Panelhoards N111-
Signature
- Z
Date 0-200 Amp Under 600 V
Signature 201 - 1000 Amp Under 600 V
By
❑ - Over 1000 Amp or Over 600 V r
Exempt.for Reg Main Elect r
SINGLE FAMILY - Tamp Power Pole d Appurtenances 2
HOME OWNER-BUILDER DECLARATIONr
I hereby affirm that 1 am exempt from the Contractors License Law Sign with One Branch Clrcun
for the following reason(Sechon 70315 Business and Profersai Additional Sign Branch Cucults - ACCT.0
Code) 37 , 20.^25
I as owner of the property will do the work and the structure Mix c°"d"'ta a G°r'd"`t°`a _ 1 ITEMS
m not intended or offered for sale (Secton 7044 Business Other(See Complete Fee Schedule) n ► TOTAL .f
and Professoro Code) - 20.25
CONSTRUCTION LENDING AGENCY - 0ECK 2ys25
I hereby affirm that there is a constriction lending agency for the owa
performance of the work for which this permit ice nssuad(Sec 3087 PERMIT FEE - (Sub-Totaj) - - .00CivC)
PLAN CHECKING FEE r1�1r��s�_�1r1r1
Lenders Name GOOD-Jyy1 7/12M
PERMIT ISSUING FEEL♦ 1 AM 9321
Larders Address �.i
.I cerbry that I have reed this appication and state that the above TOTAL FEE
information is correct I agree to comply with all County ordinances
and State Laws regulating Electrical Wong and hereby authorize
representatives of thm County emer upon the above-mentlonedl ,
I inspectmn pu os nn _SEE REVERSE FOR EXPLANATORY LANGUAGE
^ "l
orpermilt Date