HomeMy Public PortalAbout5312TEMPLE CITY BLVD_Electrical (2) WgRKERS'COMPENSATION DECLARATION 7BA66G IZ 801 8
CE- APPLICATION FOR ELECTRICAL PERMIT rel
I , U
1 hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUIL AND SAFETY
insLre;or a certificate of Workers'Compensation Insurance,or
e certified copy thereof(Sec 3800,Lab C)
FOR APPLICANT TO FILL IN ,jog 40
Policy No Company EACH NO FEE DRESS
❑ New Residential Bldgs &Pools
Certifkd copy u hereby furnished 1 &2 Famdy,Scl Ft S — S LOCALITY
Certified copy h filed with the c mty Multi family Sq Ft budding inspection CROSS ST
de ant Residential Swimming Pools . OWNER OR
/ , FIRM NAME
Date ! Applicant v Outlets Rec_Light_Sw MAIL
t , First 2F— ADDRESS
CERTIFICATE OF EXEMPTION FROM WORKERS' Total No Additional
COMPENSATION INSURANCE CITU Tel No G- Q :a.
PLAN CHECK a
APPLICANT UUV
(This se per need Trot be hundred d J the work mvohsxl Lighting Fixtures First 20
by the permtt�is for One hundred dotlan ($100) or leas) ADDRESS
Total No Additional 2
I certify that in the performance of the work for which this 1 CITU Tel No 0
permit n Issued I shall not employ any Fined Appliances Not Over 1 HP c H
P D Y Y Person in any manner PERMIT W
so as to become subject to the Workers'Compensation Laws Range— Heater_D W PP [CANT a
Oven _ Dryer_W M _ ADDRESB (� Z
Date Applicant Top _ FAU IW H
Hood _ Fan _Other_ CITY Tal Noy �_ ��
NOTICE TO APPLICANT If after making this Certificate of Disp _Room Air Cond_ ENSE OR
Exemption, you should become subject to the Workers' REG N MBE Cjass C —�
Compensation provisions of the Labor Code, you must forth Power Apparatus& Large Appliances DISTRICT NO PROC SED BY
with comply with such provisions orrthis permit shall he -
deemed revoked Size&Type HP,KW,KVA,or KVA S�Q
Up to 1 Incl INAL
ATE
Over 1 to 10 Incl i
LICENSED CONTRACTORS DECLARATION DATE VALIDATION
Over 10 to 50 Incl
I hereby affirm that I em licensed underprovisions of Chapter Over 50 to 100 InFINALc - BY /
r (commencing with ode, a d my is Division 3 ll the Bust Over 100
nes and Professions Code, end my license is In full force and
effect Services
License Num Class
�(l 0200 Amp Under 600 V ({*mac O
Lic 201 1000 Amp Under V
CIO'Contrect Dete---I��-�'e-�-V Over 1000 Amp or Overr E 800 V
HOME WNER BUILDER DECLARATION Temp Power Pole&Appurtenances
I hereby affirm that I am exempt from the Contrector'a Sign with One Branch Crrcu it 1•`VI�_/)
License Law for the following reason (Section 7031 5, Bust Additional Sign Branch Circuits
nets and Professions Code)
` Mm Conduits& Conductors
ElI as owner of the property will do the work and the Other(See Complete Fee Schedule)— ;21 3 2 S A
structure is not intended or offered for sale (Section
7044 Business and Professions Code) # • e e • e 2
CONSTRUCTION LENDING AGENCY J
1 hereby affirm that there is a construction lending agency 2 e le,1 2 0 0
for the performance of the work for which this permit is( PERMIT FEE (Sub-Total)
issued Sec 3097 Civ C
)
Lender s Name _ PLAN CHECKING FEE (Ona-Fourth Permit Fee) a • • 1200is
Lender's Address , 0924,-81
PERMIT ISSUING FEE i
1 certify that I have road 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 ,
hereby authorize representatives of this County to enter upon
the a mentio ed property for inspection p poses G _
SEE REVERSE FOR EXPLANATORY LANGUAGE
i
Signatuff of Permittee �/ � ate