HomeMy Public PortalAbout5466TEMPLE CITY BLVD_Electrical (2) WORKERS COMPENSATION DECLARATION aoaotvoPwsiar
APPLICATION FOR ELECTRICAL PERMIT _ 0
I hereby affurt that r m
have o certi(ica(e of eorLsent to self "a
insure, or c;certificate of Workers'Compensation Insurance COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
gr a certified copy thereof (Sec 3800, Lobb CC )
Policy No Company �e/T/c ���r FOR APPLICANT TO PILL IN SOB
❑Certified copy is hereby furnished New Residential Bldgs 8 Pools EACH tJ0 FEE ADDRESS
ft?l Certified copy is filed with the county building nspec- 1 8 2-Family, Sq Ft $ = f LOCALITY
^tion deportment / Multi-fomily Sq� Ft NEAREST
S7
Date Applicant�(C;��-`� Residential Swimming Pools - tt t CRCLSCAVIN1,14�
� - FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS Outlets Rec6� J_Lightf�Sw� MAIL
COMPENSATION INSURANCE ADDRESS (O
This section neid not be complifed If thi work Involved by - Total Nofirst 20 -= -
CITY Tel No
the permit Is for one hundred dollars($100)or less ) Additional CHECK
I certify that in he performance of the work for which this PIAN PLANC
permit is issued 1 shall not employ any person in any manner
ANT
so as to become subject to the Workers Compensation Laws Lighting Fixtures'L,,/1) First 20- ADDRESS
Total No Additional
Date Applicant CITY Tel No
NOTICE TO APPLICANT If after making this Certificate of Fixed Appliances Not Over 1 HP PERMIT
Exemption, you should become subject to the Workers Range— Heater—D W _ APPLICATION
Compensation provisions of the Labor Code, 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 affirm that I am licensed under provisions of Chapter 9 Disp- — Room Air Cord REG NUMBER T 0 Clow
(commencing with Section 7000)of Division 3 of the Business Power Apparatus 8 Large Appliances - DISTRICT NO p j;p g }
and Profession,Code and my license is in full force and effect I Il
'J,.��O Size 8 Type HP, KW, KVA or KVAR 0
License Number [� Lic Class _1_ Up to 1 Incl FINAL (J
Contractor _�Date;Z- VALIDATION Over 1 to 101nd DATE VALIDATION 0O
❑ Over 10 to 50 Incl FINAL
I am exempt under Sec Over 50 to 100 Inc BY W
B 8P C for this reason Over 100 / l0_
Dote Services Swbd MCC 8 Ponelboards , - Z
0-200 Amp Under 600 V -
Signature 201 - IODD Amp Under 600 V
❑
Exemption for Reg MaiOver 1000 Amp or Over 600 V `
Maim Elect
i
SINGLE FAMILY Tem Pole
HOME OWNER-BUILDER DECLARATION P Power 8 Appurtenances
I hereby affirm that I am exempt from the Contractor s License Sign with One Branch Circuit ,
Law for the following reason (Section 7031 5 Business and Additional Sign Branch Circuits, JJO7 ai„0
Professions Code) 1 ITEI'I7
t ❑ I, as owner of the property, will do the work and the Misc Conduits 8 Conductors
structure is not intended or offered for sale(Section 70”, Other (See Complete Fee Schedule)— TOTAL 31 -20
Busmess and Professions Code) CHECV 81.20
CONSTRUCTION LENDING AGENCY C `HAMI .�,
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,,Civ C )
PLAN CHECKING FEE 0000-0001 2/15/90
Lender's Name
PERMIT ISSUING FEE 3 vSN] 1 AM 940
Lender s Address -
I certify that I have read this application and state that the TOTAL FEE 'r
above information is correct I agree to comply with all County
ordinances and State laws regulating Electrical wring and -
hereby authorize re resentatwes of this County to enter upon
the above m or d proper for rnspection,puurrposes SEE REVERSE FOR EXPLANATORY LANGUAGE
2 ,1✓ 20
Signature of Permot" Date