HomeMy Public PortalAbout5450TEMPLE CITY BLVD_Electrical WORK€R SaveCOMPENSATIONcertificate
DECLARATION
to 76AM DPW(12 et) APPLICATION FOR ELECTRICAL PERMIT IJ
I hereby affirm Thel I have a certificate oL consent ro sell Insure 7�t163
or a certificate of Worker a Compensation Insurance or a certified COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV
copy thereof(Set 3800 Lab C)
Policy No Company FOR APPLICANT TO FUJI.IN JOBADDSL
lC� �t� f Jt V
❑ Certified copy to hereby fumished New Residential Bldge 8 Pools NO EACH FEE LOCALITY .J�I.J t V
❑ Certified copy M filed with the county buildng inspect" 1 6 2 Family,SKI Ft 3� — t LOCALINEARESTY �Lm
department Mulli famiry Stj Ft — CR085 ST
Date Applicant Residential Swimming Pods ASSESSOR
MPP HOOK PAGE pmica�S
CERTIFICATE OF EXEMPTION FROM WORKERS Outlets Rec —Light_Sw OWNER OR I
COMPENSATION INSURANCE I RRII NAME (� IR .1
(This section need not be completed 11 the work Involved by the Feet 20 \ oRE6s I
permit Is for one hundred dollars($100)or lees) Total No Additional Ile(
I certify that In the performance of the work for which this permit CITY z Tm Nos _coz-
Is Issued I shall not employ any person In any manner so as to PLAN CHECK
become subject to the Workers Compensation Laws Lighting Fixtures First 20 APPLX:ANT
(y I, 1 f Total NO Additional ADDRESS
Dere O P Appllrant r a i g this
C( C���C RESIDENTIAL APPLIANCES NOT OVER 3 HP
NOTICE TO APPLICANT II after making thio CerbOcete o/ CITY Tel No
Exemption you should become subject to the Workers Compensation OTHER APPLIANCES NOT OVER 3 HP ,
provisions of the Labor Code you must forthwith comply with such PPERU% T EJ
provisions or this permit shall be deemed revoked Power Apparatus 8 Large Appliances L 1✓ / L fL L
LICENSED CONTRACTORS DECLARATION Sure A Type HP KW KVA or KVAR ADDRESS C3(If
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Over 3 to 10 Ind CITY ()S Tel No IR5'00–L
Professions Code and my license is in full force and effect Over 10 to 50 Incl
�"� SE on
Over 50 to 100 Incl REGLICENNUM ER S-71 CJa
5_7_7q30 LIC Class �_(` Over 100 DS RC NO P mBY O
license,Number
'' ��--�Cy Services Swbd MCC d Panelboards J �O
Contractor Lt V C bArc C5,(c Dale ( I (g k�5 0 399 Amp Under 800 V FINAL
❑ I am exempt under Sec 400 1000 AmP Untler BOD V 0
Over 1000 Amp or Over 800 V FINAL VALIDATK7N W
B AP C for this reasonBRANCH CIRCUIT FEES SY (L
-
D to I(fibs 15A or 20A 120V Lighting or Recept z
cymnn R A ^ 1 To 10 Branch Circuits _
i l To 40 Branch Cucuns
❑ 41 Or More Branch Circuits
Exemption for Reg Maint Elect 154 2DA,20BV To 277V Lighting By Gmuas
2
SINGLE FAMILY Temp Power Pole 8 Appurtenancre -
Appurtenances;
HOME OWNER BUILDER DECLARATION Sign with One Branch Circuit
ACCT.:
I hereby affirm that I am exempt from the Contractors License Lew .I��1
for the following reason(Section 7031 5 Business and Professions Addwnai Sign Branch Cucoila t 3303 2M.30
Code) 1 ITM
❑ I as owner of the property will do the work and the structure Mm Conduas 8 Conductors
Is not mtencied or offered for sale (Seclton 7044 Business Other(See Complete Fee Schedule) , TOTAL 280. 30
and Professions Code) IDECK 2M.30
CONSTRUCTION LENDING AGENCY 4l1LCf>itiT1zG MI hereby affirm that there Is a construction lending agency for the
performance of the work for which this permit is issued(Sec 3097 PERMIT FEE (Sub Total 3 O 0
Civ C)
PLAN CHECKING FEE 0000-0001 1/18/96
Lender s Name �1 4324 1 AM10:06
PERMIT ISSUING FEE �I pa/
Lenders Address TOTAL FEE p d 3
I randve y that I haread this eppllcpenalty d on aunder penalty purjury elate
that the above Information is correct I agree to comply with all County
ordmances and Stale Is ws regu Ing EIecVlcalwinng andherebyauthonze
repnesen d this County enter upon the abo mentwned property
for In u SEE REVERSE FOR EXPLANATORY LANGUAGE
s,u,,,TjmE OF PERMITTEE M