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HomeMy Public PortalAbout5349TEMPLE CITY BLVD_Electrical (2) Worm thahave COMPENSATION DECLARATIONcorse CE 863 ID,BI APPLICATION FOR ELECTRICAL PERMIT I hereby affirm that j have a certificate of convent to self ��' msure or a certificate of Workers Compensation Insurance COUNTY OF LOS ANGELES BUILDING AND SAFETY or a certified Ropy thereof (Sec 3800 Lab C ) Policy No Company FOR APPLICANT TO FILL IN ADDRESS % Ein / p z Certified copy is hereby furnished New Residential Bldgs 8 Pools EACH NO FEE Q Zoe F� ❑ f — s Certified copy is filed with the county building mspec_ 1 8 2 Family, Sq Ft LOCALITY tion department Multi family Sq Ft NEAREST ST tV L S Date Applicant Residential Swimming Pools CROOWNEROR q FIRM NAME CL CERTIFICATE OF EXEMPTION FROM WORKERSLightMAIL Outlets Rec COMPENSATION INSURANCE Sw_ ADDRESS(ThS V First 20 the permissH:tIt I nor not un red leteddolga If the work Involved by Total No Additional CITY � C L Tel No the permit IF for one hundred dollars($100)or IeiF) H CL-0( I certify that in the performance of the work for which this PIAN PLAN CHECK Permit n issued I shall not employ any person in any manner so as to become subject to the Wrs,Compensation Laws Lighting Fixtures First 20 ADDRESS a ' Additional Tel No Date 'D 7 Appbcan F Total No CI fixed Appliances Not Over 1 HP PERMIT 'NOTICE TO APPLICANT If after making this Certificate of PERMIT Exemption you should become subject to the Workers Range_ Hooter_D W Compensation provisions of the Labor Cade you must forth- Oven _ Dryer _ W M — ADDRESS with comply with such provisions or this permit shall be Top _ FAU —W H — deemed revoked Hood _ Fan _Other_ CITY Tel No LICENSED CONTRACTORS DECLARATION LICENSE OR I hereby off irm that I am licensed under provisions of Chapter 9 Disp Room Air Cond REG NUMBER Class (commencing with Section 7000) of Division 3 of the Business Power Apparatus 8 Large Appliances DISTRICT NO / PROCESSED V T and Professions Code and my license is in full force and effect L/,!/QI( d Size 8 Type HP KW KVA, or KVAR O License Number L,c Class Up to I Incl - FINAL 17 V 2 Contractor Date Over 1 to 10 Incl DATE Z y VAU ION 0 ❑ Over 10 to 50 InFINA I am exempt under Sec Over 50 to 100 Inc BY74) d B BP C for this reason Over 100 = Date Services Swbd MCC 8 Ponelboards �7 4 Q 5 A 0 200 Amp Under 600 V # • • • 2 Signature 201 1000 Amp Under 600V # ❑ Exemption for Reg MaOver 1000 Amp or Over 600 V I • s 2 ,5 mt Elect SINGLE FAMILY Temp Power Pale 8 Appurtenances • s s 2 5 5 Q 1-' HOME OWNER BUILDER DECLARATION Sign with One Branch Or Icwts .7 6 -8 7 I hereby affirm that I am exempt from the Contractor s License - Additional Sign Branch Cv - # Q Low for the following reason (Section 7031 5 Business and - Prpfessions Code) IICY_11 I as owner of the property will do the work and the Misc Conduits&Conductors structure is not intended or offered for sale (Section - Other (See Complete Fee Schedule)_ ► 7044 Business and Professions Code) - CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued PERMIT FEE - (Sub-Total) - (Sec 3097 Gv C ) - - PLAN CHECKING FEE- Lender s Name � PERMIT ISSUING FEE t Lender's Address ^ �� I certify that I have recd this application and state that the _ TOTAL FEE �(J r above information is correct I agree to comply with all County ordinances and State laws regulating Electnml wiring and hereby authorize representatives of this County to enter upon It ve mentioned property for inspection purposes - SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Per ittee Date