HomeMy Public PortalAbout5313TEMPLE CITY BLVD_Electrical (2) • WORKERS COMPENSATION DECLARATION 7a`W I0i9I
here" FOR ELECTRICAL PERMIT q
I hereaffirm that I have a certificate of consent to self CE BOAC IJ
.insure or a certificate of Workers Compensation Insurance COUNTY OF LOS ANGELES BUILDING AND SAFETY
or o certified copy thereof (Sec 3800 Lab C )
Policy No Company FOR APPLICANT TO flu w ADR �3/3 T�MPLECITY B1-✓D
CertifiedEACH NO FEF ESS
copy is hereby furnished New Residential Bldgs & Pools I
Certified copy is filed with the county building mspec 1 8 2-Fomily Sq Ft $ — f LOCALITY T PL,.4- C t Y
non department Multi family Sq Ft NEAREST /
Residential Swimming Pools ' L•� '// O
Dote Applicant OWNER Q V
' FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS Outlets Rec_Light_Svv_ ['(
COMPENSATION INSURANCE I ' ADDRESS -S3/3 7Y 46""0
(This section need not be completed R the work Involved by First 20
the permit Is for one hundred dollars ($100)or Im ) Total No Additional CITY-TEf('P4'cr C17Y Tel No�249(0•2z
I certify that in the performance of the work for which this PLAN CHECK
permit is issued I shall not employ any person in y ma rmor APPLICANT
so as to become subject to the Workers Com non Laws Lighting Fixtures First 20 ADDRESS
` . Total No Additional
CITY Tel No
Dote �� ^�3_ ppbmnt �
NOTICE TO APPLICANT If after making this Certificate of Feed Appliances Not Over 1 HP PES
Exemption, you should become subject to the Workers Range_ Heater_D W _ APPLICANT
Compensation provisions of the Labor Code you must forth- Oven _ Dryer _W M _ ADDRESS
•with comply with such provisions or this permit shall be Tap _ FAU —W H
,deemed revoked Hood Fan _Other_ CITY Tel No
_
LICENSED CONTRACTORS DECLARATION DCENSE OR
I hereby affirm that I am licensed under provrsiam of Chapter 9 Disp — Room Air Cond REG H Class
(commencing with Section 7000)of Division 3 of the Business power Apparatus 8 Large Appliances DISTRICT NO SSED BY }
and Professions Code and my license is in full force and effect
I Size 8 Type HP, KW KVA or KVAR QQ i
License Number La Class-
- Up to 1 Incl FINAL
Over 1 to 10 Incl f4 DATEQ
Contractor Dote VAUDATIO 0
O Over 10 to 50 Incl FIN U
I am exempt under Sec Over 50 to 100 Inc BY 0.
W
100 V)
B 8P C for this reason Over to
Z
Dote Services, Swbd , MCC 8 Ponelboards
0 200 Amp Under 600 V ix
Signature 201 1000 Amp Under 600 V $5 7 M A
Over 1000 Amp or Over 600 V
Exemption for Reg Mamt Elect 0 Q O O—02
SINGLE FAMILY Temp Power Pole 8 Appurtenances Q
' HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit 2
I hereby affirm that I am exempt from the Contractw s License
Law for the following reason (Section 7031 5 Business and Additional Sign Branch Circuits # e e s 0,0.2
W ro""bons Code)
as owner of the property will do the work and the M,w Conduits&Conductors I • e .3 2 Jr 0
structure is not intended or offered for sale (Section Other (See Complete Fee ess Schedule)_ Poo see 32505
7044 Businand Professions Code)
CONSTRUCTION LENDING AGENCY O 2
I hereby affirm that there is o construction lending agency forte
the performance of the work-for which this permit is issued PERMIT FEE' (Sub-Total)
(Sec 3097 Civ C )
PLAN CHECKING FEE
Lender s Name
PERMIT ISSUING FEE Q
Lender s Address
I certify that I ho v read this appl¢at on and state that the TOTAL FEE ,
above inform itio s correct I ogrea to comply with all County
ordinances and S§6te jaws regulating Electrical wiring and r
h by authoriz e r sentotives of this County to enter upon
t Bove ed props or inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
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