HomeMy Public PortalAbout5454TEMPLE CITY BLVD_Electrical (2) 1 - YIQRKERS COMpEWSATION 6EGLARATION GEE p,B, APPLICATION FOR ELECTRICAL PERMIT JI
l I hereby affirm that I h96e a certificate of consent to sell msure 06G y I
I or a certificate of Workers Compensation Insurance or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY lul
copy dvreyf(Sec 3800 Lab C)
` Policy No Cornpary FOR APPLrANT TO FILL IN JOB
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Certified copy a hereby furnished New Reademal B EACH NO FEE
AD
Sleet Fbds — LOCALITY
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Certified copy a bled with the county bolding inspection 1 8 2-Family Sq Ft $ — S
department Multi family Sq Ft NEAREST
GROWDale Applicant
Reedental Swimming Pools OWNEp BOR
FIRM NPME
CERTIFICATE OF EXEMPTION FROM WORKERS '�1 t MAIL
Outlets Rec J_(e. Light Sw
COMPENSATION INSURANCE wlxlEss
-- -(This section need not be completed M the work Involved by the Fara[20 _ _
permrt Is for one hundred dollars($100)or lase) Total No Additional CR1' T No
I certify, that in the performance of the work for which this permit PLAN GAECK
is issued I shall not employ any person in any'manner so as to iAPPUCANT
become su get t the Workers CompensatioAC1,bt.t.
Lighting Fixtures First 20 ADDRESS Additional
Date Applicant Total No � CITY Tel No
NOTICE TO APPLICANT If eft ekinFixed Appliances Not Over 1 HP PERMIT
Exemption you should become sub)ect to the Workers CoMpensaton Range_ Heater_ DW _ APPLICANT
provisions of the Labor Code you must forthwith comply with such Oven — Dryer — W M — -ADDRESS
provisions or this permit shall be deemed revoked Top — FAU _ WH _ . r
CITY Tel No '-
LICENSED CONTRACTORS DECLARATION Flood — Fen Other_
I hereby affirm that 1 am lic"ed urder provisions of Chapter g Dap'— Room err Gond LICENSE OR
(cClaw
ommencing with Section 7000)of Division 3 of the&lamest, and REG NUMBER
Pmfessons Code and my Incense is in full force and effectDISTRICT NO PRD ,SE
Power Apparetu9 8 Large Appliances J ,
Size&Type HP KW KVA or KVAR O
License Number I-c Class Up to 1 Incl FINAL O
Over 1 to tO Incl DATE VALIDATION
Contractor Date Over 10 to 50 Incl❑ 0 FINAL U
I am exempt under Sec Over 50 to 100 Inc By W
e&PC for this reason Over 100 G.
V1
�r'^c0-Swbd MCC d 600 PaV ds S O , _ Z
Date
0-200 Amp Under 800 V k..7 c"
Signature 201 - 1000 Amp Under 800 V _
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Exemption Over 1000 Amp or Over 600 V
Exemption lion Reg Maim Elect
SINGLE FAMILY Temp Power Pole& Appurtenances 2
HOME OWNER-BUILDER DECLARATION �``"TeA -
I hereby affirm that I am exempt from the Contractors License Law Sign with One Branch Circuit
for the following reason (Section 7031 5 Business and Profesams Additional Sign Branch Cirands 3W 42.00
Code) - •7JY!
.� Mac Conduits 8 Conductors 1 ITM
I as owner of the property volt do the work and the structure
is not mterded or offered for sale (Section 7044 ureas Other(See Complete Fee Schedule) _ TOTAL 42.00
and Professions Code) ► -
CONSTRUCTION LENDING AGENCY
WWCK42e�M
I hereby affirm that there Is a construction lending agency for the '� CHAIM •00
performance of the work for which this permit is issued(Sec 3087 PERMIT FEE (Sub-Total) ,
Cry C)
Lenders Name ��1rIr�_�vr1ry
PLAN CHECKING FEE WIJL7""{JI7H1 8/25M
'
PERMIT ISSUING FEE (04) 3314 1 AM10159
Lenders Address
I certify that I haws read this application and state that the above Tisa-FEE
n(crmatlon is correct I agree to comply with all County ordinances
and State laws regulating Electncal wlnng and hereby authorize ,
representatres of this County to enter upon the above-mentoriod +
prop for Irlspechi: our es SEE REVERSE FOR EXPLANATORY LANGUAGE
Signalure of Permittee De