HomeMy Public PortalAbout5442TEMPLE CITY BLVD_Electrical (2) WORKER I have a certificate
DECLARATION AW DPW„2 a„ APPLICATION FOR ELECTRICAL PERMIT
hereby affirm that I have a certllicate of consent to self insure
certificate of Worker a Compensation Insurance or a certified COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING ND AFETY DIV
thereof(Sm 3800 Lab C)
Policy No Company FOR APPUCANT TO RLL IN .108
ADORERS
❑ 'Cerld*d copy is hereby furnished New Readential Bldgs 8 Poole _ NO I EACH FFA LOCALITY
❑ Csrtdied copy is filed with the county building Inspection 1 8 2 Family Sq Ft — $ 3
department Multi-family Sq FI — N
EAR
tmCAOS,q sr
Date Applicant Residential Swimming Pools ASSESSOR
MAP BOOK PAGE PARCEL 10676
CERTIFICATE OF EXEMPTION FROM WORKERS Outlets Rec �Light Sw OWNER OR
COMPENSATION INSURANCE I I 4p FIRM NAME /f
First 20 MAIL
(arts sect is for need not d completed(51 0 the work Involvmmtl by the Total No Addnwnal '�' I` L 1 \ tADDREW
permR Is for one hundred dollen((1100)or Iasi)
I certify that in the performance of the work for which this permit CITY TN No /
is Issued I shell not employ any person in any manner sn as to 00PLAN CHECK `
become subject to the Workers Compensation Laws Lighting Fixtures First 20 ""PLIGHT
Total No � Additional ADDRESS
Date a - d,7-1 Applx:ent RESIDENTIAL APPLIANCES NOT OVER 3 HP
NOTICE TO APPLIC T It alter mekmg this Certificate of CITY Tsl No
Exemption you should become subfect to the Workers Compensation OTHER APPLIANCES NOT OVER 3 HP
provisions of the Labor Code you must forthwith comply with such PEANUT
provisions or this Permit shell be deemed revoked
Power Apparatus d Large Appliances APPUCIANT
LICENSED CONTRACTORS DECLARATION Size 8 Type HP KW KVA or KVAR ADDRESS
I hereby affirm that I am licensed under provisions of Chapter 9 _2f Over 3 to 10 Incl
(commencing with Section 7000) of Division 3 of the Business and CITU Ta No
Professions Code and my license is in full force and effect Over 10 to 50 Inc]
Over 50 to 100 Incl UCEN Oleo d
REO NUMBER
Lucerne Number Lk Clean
Over I W DISTRICT NO P BY O
❑ •�� V
Contractor e DATES3Dete Serwc� �d 0V O
– H
I am exempt under Sec ���Am p Under
n�600
V VALIDATION W
B 3P C It this reason BRANCH CIRCUIT FEES BBYY1AL �
Date ISA a 2DA 120V Ughbng or PAKWI Z
Signature 1 To 10 Branch Circuits
11 To 40 Branch Circuits
❑ 41 Or More Branch GrcuW
Exemption for Reg Mart Elect 15A 20A 208V To 277V Ughtnif Br Grants �L
SINGLE FAMILY Tempower PPole&Appurtenances 2
HOME OWNER BUILDER DECLARATION waM One Branch Circuit I hereby affirm that I am exempt from the Contractor a License Law SignT•a>r
for the following reason (Section 7031 5 Business and Professions Additional Sign Branch Circuits Tfn� 92.30Cotly .�.TlJ.7
1 as owner of the property will do the work and the structure Mm Conduits 8 Conductors 1 ITEMS
EMS IJ
is not Intended or offered for sale (Section 7044 Business Other(See Complete Fee Schedule)_ ' TOTAL 92. 30
and Professions Code) CHECK 92.30
LENDING AGENCY •30
1 hereby affirm that there Is a construction lending agency for the A•zR
penormance of the work for which this permit Ia Issued (Sec 3087 PERMIT FEE (Sub-Total
Civ C) MP�nOnzs–�nTsrr��nv
PLAN CHECKING FEE wW–WU1 2z�/ks29/96
LeMer a Name PERMIT ISSUING FEE Nlz7L/ 1 TII 6:19
Lender a Address
I certify that I have read thus applk;ation and under penalty or purlury State TOTAL FEE 3
that the above mfermation is coned 1 agree to comply with a8 County `
ordinances and State lawn regulating Electrical wrung and hereby authonze
representatives of 1 a County to enter upon the above mentioned property
for pecten P SEE REVERSE FOR EXPLANATORY LANGUAGE
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NATURE or,PEmwrrE# DATE