HomeMy Public PortalAbout5039TEMPLE CITY BLVD_Electrical WORKERS COMPENSATION DECLARATION 78A663 ICEb06G 12801.. APPLICATION FOR ELECTRICAL PERMIT ,
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1 hereby affirm that I have a certificate or cotuent to ,If -COUNTY OF LOS ANGELES BUILDING AND SAFETY
Insure or a certificate of Workers Compensation Insurance,or �.
a certified copy thereof(Sec 3800, Lab C) 1
I FOR APPLICANT TO FILL IN JOB j7G39 TEM PLIC
Policy No Com peny
New Residential BldgEACH NO FEE ADDRESSs &Pools _
❑ Certified copy u hereby furnished 1 &2 Family,Sq Ft a $ — $ LOCALITY 7'E N/P1 �. C I T
❑ Certified copy Is fled with the county buildinginspection Multi-family Sri Ft CRO
A
department Residential Swimming Pools OWNE�RSOR ^ t�-
r -+ FIRM NAME v4,-14 S
Date ,Applicant i 1 MAIL
Outlets FIRM
First 20
20 ADDRESS 503,/\T�M�r1 Cf U ✓7
CLRTIFICATE OF EXEMPTION FROM WORKERS Total No' - Atldmonal_ - -- _" CITY- -
COMPENSATION INSURANCE 7FN/��Tz G C - Tal No 287_3 Efti
_ PLAN CHECK d
r O
(This section need not be completed if the work involved APPLICANT
First U
by the permit u for one hundred dollars (5100) or less) Lighting Fixtures Addi20 ADDRESS
Total No Addtional �
1 certify that in the performance of the work for which this Fixed Apphancas Not Over 1 HP CITY '� Tel No O
permit u Issued 1 shall not employ any person in any manner PERMIT
so as to become subject to the Workers Compensation Laws Range_ Heater_DWAPPLICANT W,
i Oren _ Dryer_W M ADDRESS C� N
Date Applicant Top _ FAU _WH _ Z
Hood _ Fan _Other_ CITU Tal ,
NOTICE TO APPLICANT If, after making this Certificate of Disp _ Room Air Cond_ L CENSE OR '
Exemption you should become subject to the Workers REG NUMBER Clan
Compensation provisions of the Labor Code you must forth Power Apparatus& Large Appliances DISTRICT NO PRO§:ESWb BY
vnth comply with such provisions or this permit shall be Size&Type HP KW KVA or KVA
deemed revoked r
p to 1 Incl FINAL
' LICENSED CONTRACTORS DECLARATION to 10 Incl DATE VALIDATION .
Over 10 to 50 Incl —
I hereby affirm that I em licensed under provisions of Chapter Over 50 to 100 Inc FIN L
9 (commencing with Section 7000)of Division 3 of the Busl Over 100 BY
ness and Professions Code and my license is in full force and
effect Services
Q200 Amp Under EDO V _
License Number L¢ Class 201-1000 poop Under 600 V '
Contractor. Date Over 1000 Amp or Over 600 V
r
HOME OWNER BUILDER DECLARATION Temp Power Pole&Appurtenances
l1
1 hereby affirm that 1 em exempt from the Contractor's Sign with'One Branch Circuit
Additional Sign Branch Circuits 9 1 7 6 4 A
ices, Law for the following reason (Section 7031 5, But
nese ?dLaw
Code) #,• a e a'a 2
Mim Conduits&Conductors
1 as owner of the property wdo the work and the Other(See Complete Fee Schedule)— 2 •i• 1450
structure is not intended or offered
ered for sale (Section _
7044 Business and Professions Code)
CONSTRUCTION LENDING AGENCY • • • 1 4.50e
I hereby affirm that there is a construction lending agency -
for the performance of the work for which this Permit a PERMIT FEE (Sub Total) ` ( Q 3 1 —8 1
issued(Sec 3097 Civ C) ' -
Lender's Name PLAN CHECKING FEE (One Fourth Permit Fee) -
Lender s Address PERMIT ISSUING FEE
I certify that I have read this application and state that the TOTAL FEE
above information u correct 1 agree to comply with all County r -
ordmances and State laws regulating Electrical wiring and
hereby authorize representatives of this County to enter upon
the above mentioned property for mapection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
ezz l . /���•a07_ � /O Z�� mob' ,
Signature of Permittee Date' , "`