HomeMy Public PortalAbout5220TEMPLE CITY BLVD_Electrical (2) ,.4\
" WORKERS COMPENSATION DECLARATION 63 IDrel APPLICATION, FOR ELECTRICAL PERMIT
I hereby affirm
8SG
m shot I have a certificate of consent to self [E B
insure or a certificate of Workers Compensation Insurance COUNTY OF LOS ANGELES '� BUILDING AND SAFETY
or a certified copy thereof (Sec 3600 Lab C ) ,Q
Policy No Company FOR APPLICANT TO Nll IN DDRE55
Certified copy is hereby furnished New Residential Bldgs & Pools EACH' NO FEE
Certified copy is filed with the county building inspec 1 & 2-Family Scl Ft _ = f LOCALITY
hon department Multi family Sq Ft NEAREST
CR059 S,
Date Applicant Residential Swimming Pools OWNER OR Q
FIRM NAME i.JO�Yv✓/G
CERTIFICATE OF EXEMPTION FROM WORKERS Outlets Rec_Light_Sw_ MAIL
COMPENSATION INSURANCE ADDRESS eAy
(This section nod not be completed H the work Involved First 20 uz,��-
p by Total No Additional CITY / Tel No /)v
the permit Is for one hundred dollen (f100)or less) PIAN CHECV
I certify that in 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 sub j t to the Workers �qis hon Lighting Fixtures First 20 ADDRESS
S, 0r �/(/ Total No Additional
Dote Applicant CITY el No
NOTICE TO APPLICANT If after mak9g this Certificate of Fixed Appliances Not Over 1 HP APPPU T T
Exemption you should become subject to the Workers Range_ Heater_D W — _ '
Compensation provisions of the Labor Code you must forth Oven _ Dryer _ W M — ADDRESSc,
,with comply with such provisions or this permit shall be Top _ FAU _W H — �op-
deemed revoked CITY gyp/ � ,OA-_V r` Tel No 00 o/
LICENSED CONTRACTORS DECLARATION Hood _ Fan _Other_
I hereby affirm that I am licensed under provisions of CFwpter 9
Dtsp _ Room Air Card —� �NNUMBER 913 Class
(commencing with Section 7000) of Division 3 of the Business Power Apparatus &Large Appliances DISTRICT NO� �� PROCE D B '
and Professions Code and my license is in full force and effect O
3s�z79 Size 8 Type HP, to Ind or KVAR Cg
License Number tic Class ` /O FINAL �
✓ Up to 1 Incl
�9��Y/ g�7 Over 1 to 10 Incl DA's � g V DATION O
Connector_ Dote❑ Over 10 to 50 Incl U FIN W
I am exempt under Sec Over 50 to 100 Inc
B 8P C for this reason 100 Z
on '1 Z
0 Services Swbd , MCC 8 Ponelboords ,L� UK
t 0 -20O Amp Under 600 V
SignatureIV— 201 - 1000 Amp Under 600 V
Over 1 ODD Amp or Over 600 V B-52 L 6 A
0 Exemption for Reg Maint Ltp e e e *.e2
SINGLE FAMILY Temp Power Pole&Appurtenances
HOME OWNER BUILDER DECLARATION Sign with One Branch Circuit ( e - 2550
1 hereby affum that I am exempt from the Contractor's License gddatorwl Sign Branch Grants
Law for the following reason (Section 7031 5 Business and g e e e 2 5 5 0 5
Professions Code) O v ' `8 6
Mist Conduits 8 Conductors
I as owner of the property will do the work and the Other (See Complete Fee Schedule)_ , t
structure is not intended or offered for sale (Section
70" Business and Professions Code)
CONSTRUCTION LENDING AGENCY
I hereby affum that there is a construction lending agency for
the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) O
(Sec 3097 Ctv C )
PLAN CHECKING FEE
Lenders Name
PERMIT ISSUING FEE
lender s Address
I certify that I have read this application and state that the TOTAL FEE fS
above information is correct I agree to comply with all County
ordinances and Slate laws regulating Electrical wiring and
hereby authorize representatives o th to enter upon
the above-: t propertyf r purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Pe4fitttee Date