HomeMy Public PortalAbout5504TEMPLE CITY BLVD_Electrical (2) WORKERS COMPENSATION DECLARATION 20aai9DIPw3rV APPLICATION FOR ELECTRICAL PERMIT O
I hereby offirm f bi I have a certificate of consent to self
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insure, or'a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
or a certified copy thereof (Sec 3BOD,fpl�5 ) _ r r
Policy No Company N �1TWL� FOR AMICANT TO FILL INJOB („
❑Certified copy is hereby furnished New Residential Bldgs B Poo EACH NO FEE ADDRESS 7
❑ Ll- CAU
Certified copy is filed with the county building inspec 1 S 2-Fomdy, Sq Ft $ — $ LOCALITY ale—'rC
hon deportment Multi family Sq Ft — NEAREST
CROSS ST
Residential Swimming Pools OWNER /1 s Ii
Dote—Applicant FIRM NAME I"1 Y
CERTIFICATE OF EXEMPTION FROM WORKERS Outlets Rec_Light_Sw= MAIL l t
Blvd
COMPENSATION INSURANCE First 20 ADDRESS G
(This section need not he completed If the sverk Inwbred by Total No Additional - CIT Tel o
the pentsff Is for one hundred dollors($100)or less)
I certify that in the performance of the work for which this - PLANCAM
APPLICANT
is issued I shall not employ any person in any manner
so as to become sublect to the Workers Compensation Laws Lighting Futures First 20 ADDRESS
Addmonal
Applicant Total No CITY Tel No
Dote
Fix
NOTICE TO APPLICANT If, after making this Certificate of
ed Appliances Not Over 1 HP PERMIT
Exemption you should become subject to the Workers Range— Heater—DW _ 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 T — FAU —W H — `
deemed revoked Hood — Fan —Other_ CIN _ Tel No '
I LICENSED CONTRACTORS DECLARATION Dnp — Room Air Cord — LICENSE OR Class
(commencing with Section 7000)of Division 3 of the Business Power Apporotus 8 Large Appliances DISTRICT f` fff///� p SSED
and Professions Code and my license is in full force and effect GS D� >
CL
Size 8 Type HP, KW, KVA w KVAR ✓ O
License Number Lic Class Up to 1 Incl FINAL U
Over 1 to 10 Incl DA's -I' VALIDATION IS
,t
Contractor ate Over 10 to 50 InO
FINAL F
❑ I am exempt under Sec Over 50 to 100 Inc BY 0
LU
B 8P C for this reason Over 100 O_
Services, Swbd , MCC 8 Panelboards _
Date
0 200 Amp Under 600 V
Z
Signature 201 - I000 Amp Under 600 V �I x 00
❑ Exemption for Reg Moira Elect Over 1 ODD Amp or Over 600 V
SINGLE FAMILY Temp Power Pole 8 Appurtenances ^
HOME OWNER BUILDER DECLARATION ti
I h by affum that I am exempt from the Contractor's License Sign with One Branch Circuit ' D O �T x;
La fw the following reason (Section 7031 5 Business and Additional Sign Branch Circuits Pr essionsCode) 3307 31.00
1 as owner of the property, Mnc Conduits&Conductors 1 ITEMS
p perry, will do the work and the Other See Complete Fee Schedule C11J
structure a not intended or offered far sole(Section 7064, ( P )— , TOT .3' 1 00
Business and Professions Code)
CONSTRUCTION LENDING AGENCY CHECK 31.00
I hereby off irm that there is a construction lending agency for
the performance of the work for which this permit is issued PERMITFEE (Sub Total) UNIZ x00
(Sec 3097 Civ C ) -
PLAN CHECKING FEE
Lender's Name _
PERMIT ISSUING FEE 0000-0001 1r1/90
Lenders Address TOTAL FEE — 9616 1 AM10:+8
I certify that I have rood this application and state that the
above information is correct I agree to comply with all County ) -
ord nces and State jaws regulating Electrical wiring, and ,
reby uthonze repro ntatives of this County to enter upon
abo -mentio r for inspection ,poses SEE REVERSE FOR EXPLANATORY LANGUAGE
i re o Permnree inspects;
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