HomeMy Public PortalAbout5039TEMPLE CITY BLVD_Electrical (2) WORKrm that I have aTION�SECLARATION 7EA863 _ APPLE ATION FOR ELECTRICAL PERMIT
�7SA66 G (2 BO)
I hereby affirm that I have a certificate of consent to rest COUNTY OF LOS ANGE ES BUILDING AND SAFETY
insure or a certificate of Workers'Compensation Insurance,or, i
e certified copy thereof(Sec 3800,Lab C) -
Policy NO Company FOR APPLICANT TO FILL IN JOB / 8 Poo
New Residential Bldgs &Pools EACH NO FEE ADDRESS
❑ Certified copy is hereby furnished 1 &2 Family,Sq Ft S — 4 LOCALITY 72� /�f/� C i—
❑
Certified nopy u with Multi family Sri Ft
filed th the county building inspeion Residential Swimming Pools CROSS ST
department
i FIRM NAMEVqHf}N 5 , B�DRos►pN
Date Applicant Outlets Rec_Light SW MAIL �"03 Tc/'//�G� Ci 1 'U✓�
—Fast 20 ADDRESS
CERTIFICATE OF EXEMPTION FROM WORKERS' C / Tel No
COMPENSATION INSURANCE Total No Additional CITYT�ryft6' 7 F7-36x0 >
PLAN CHECK i is.
(Chis section need not be completed If the work Involved Lighting Fxtu res First 20 APPLICANT U
by the permit Is for one hundred dollars ($I00) or leni) e e Additional ADDRESS
Total No fh
1 comfy that m the performance of the work for which nor Fixed Appliances Not Over 1 HP CITY Tel Na (7U.
Permit n issued, 1 shell not employ any person In any manner PERMIT W
so as to become subject to the Workers' Compensation Laws Range_ Heater_DIN APPLICANT
Oven _ Dryer_W M _ ADDRESS IV fz�
Date Applicant Top _ FAU _WH _ z
Hood _ Fan _Other_ CITY el No
NOTICE TO APPLICANT If after making this Certificate of MID _ Room Air Cond_ R
Exemption, you should become subject to the Workers RE NUMBER Cleo
Compensation provisions of the Labor Code, you must forth Power Apparatus& Large Appliances DISTRICT NO PR D BY
with comply with such provisions or this permit shall be �y
deemed revoked Size&Type HP KW KVA,or KVA (�/®r/
Up to 1 Incl dip
Over 1 to 10 InclFINAL
LICENSED CONTRACTORS DECLARATION
DIDATEj2 r/ ,� VALIDATION
Over 10 to 50 Iml !/I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc
9 (commencing with Section 7000)of Drvuion 3 of the Bust Over 100
ness and Professions Code and my license is in full force and
effect Services A
License Number Uc Clan 201
Amp 'Under 600 V
201 1000 Amp Under 600 V -
Contractor Date Over 1000 Amp or Over 600 V
HOME OWNER BUILDER DECLARATION Temp Power Pole&Appurtenances
1 hereyy ffirm that I am exempt from the Contractor's Sign with One Branch Circuit /
Liceas w for the following reason (Section 7031 5, But Additional Sign Branch Circuits _ 2 5 3 a 2 A
nws d Profesnons Code) i '
Min Conduits&Conductors n • •;• • • 2
1, as owner of the property will do the work and the Other (See Complete Fee Schedule)— 2 • • 1950
structure o not intended or offered for sale (Section
7044, Business and,Professions Code) ,. . • 1 9 5 0 F'
CONSTRUCTION LENDING AGENCY ,
1 hereby affirm that there is a construction lending agency
for the performance of the work for which this permit Is PERMIT FEE (Sub-Total) S2i6 -8
issued (Sec 3097 Civ C) ,
Lender aNamei
PLAN CHECKING FEE '(One-Fourth Permit Feel I
Lender's Address PERMIT ISSUING FEE
1 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 i
hereby authorize representatrvea of this County to enter upon
the above property for inspection os is SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date