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