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HomeMy Public PortalAbout5441TEMPLE CITY BLVD_Electrical (2) ION WORKER I have a certificate of consent to A683 Y.'(,2 a„ APPLICATION FOR ELECTRICAL PERMIT IJ Thereby aRum IILet 1 have a cernOcete of consent to Belt mauve or a certificate of Worker a Compenaetho;Insurance or a certified COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV r copy thereof(Sec 3800 Lab C) /,/ /� /� y Policy No Company iOR APPDCANT TO ALL al JOB ADDRESS SYY �E� li:. V/ O[ ❑ Cemlied copy is hereby Iurnlshetl New Residential Bldgs 8 Pools 1 NO $ EACH $ FEE LOCALITY T ❑ _ Certm lhed copy Tilsit with the county building182 Family Sp Ft building Inspection NEARE � depertmant Multi family Sq Ft CROSS UT Date y7e- Date Applicant Residential Swimming Poole ASSESSOR ,, MAP SOCK PAGE PARCEL CERTIFICATE OF EXEMPTION FROM WORKERS Oadets Ret JL Light�Ssr 4" RMPM R OR COMPENSATION INSURANCE_ 0 Ebel 20 MAIL /� y (Thio t Issection and not M completed 0 the work Involved by the Total No24,151, Additional ADOREss S I % C, O LVD parrnll la for one hundred dollars($100)or Ina) /^1 1 certify that In the performance of the work for which this permit CITY CI 2Y7—W r is Issued I shell not employ any person in any manner so as to PLAN CHECK become subject to the Workers Compensation Laws Lighting Fixtures First 20 APPLICA Total No � Additional ADDRESS Date ^ Applicant RESIDENTIAL APPLIANCES NOT OVER 3 HP NOTICE TO APPLICANT If after making this Certificate of CITY TN W ' Fxempbon you shouldibscome subject to the Workers Compensation OTHER APPLIANCES NOT OVER 3 HP' Aprovisions of the Labor Code you must forthwith comply with such PPMLICANT �' Power Apparatus 8 Large Appliances provisions or this permit shall be deemed revoked i ' LICENSED CONTRACTORS DECLARATION Srza&Type HP KW KVA a KVAR _ ADDRESS I hereby affirm that I em licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Over 3 to 10 incl CITY TO Ro Professions Code and my license is In full force and effect Over 10 to 50 Incl Over 50 to IDO Ind REG NUMBER (]ma d License Number LK: Clara Over 100 DISTRICT NO p PmROC 95BY O SerrKms Swo M 8C Parutl&gards ContractorDeis n er V DATE ❑ I am exempt under Sec 400 1000 Amp Under 800 V ~ VALIDATION' U Over 1000 Amp or Over 800 V RHAL W B AP C for Nu reason- BRANCH CIRCUIT FEES BYa. Z4 J z Date 15A or 20A 120V Lighting or Racept - L —yI/ z 1 To 10 Branch Circuits Signature 11 To 40 Branch Circuits i 41 More Branch Circuits ❑ Exemption for Reg Men77Vt Elect 15A,20A,2DBV To 2OLighmlg Br Corals 2 SINGLE FAMILY Temp Power Pale A Appurtenances • a HOME OWNER BUILDER DECLARATION ACCTar I hereby affirm that I em exempt from the Contractors License Lew Sign with One Branch Circuit for the following reason(Section 7031 5 Business and Professions Additional Sgn Branch Circuits 1 _ _ M7 �1��kA� 1�•�`' Code) _ __ _ _ 1 IIL11i7 1 as owner of the property will do the work and the structure Misc Concurs&Conductors 1 Is not Intended or offered for sale (Section 7044 Business Other(See Complete Fee Schedule)_ ' TOTAL _ 108_33 OfECK 1 .3.3 and Professions Code) -- - - _ CONSTRUCTION LENDING AGENCY •00 I hereby affirm that there Is a construction lending agency for they performance of the work for which this permit is issued Sec 3097 PERMIT FEE i pe p ( (Sub Total) _ Civ C) PLAN CHECKING FEE OOOU-0001 11/16/91 Lender s Name PERMIT ISSUING FEE 06518 1 AM10:51 Lender s Address I certify that I have read this application and under penalty of purlury state TOTAL FEE Net the above mfoimetmn IS coned I agree to COMPy with all County ordinances and Slate laws regulating Electrical wiring and hereby authorize representatives of this Ccunry to enter upon the above mentioned property for Inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE t/1 A0. 1(—/G ^ g1— KATIRE of PeRw DATE