HomeMy Public PortalAbout5717-5719TEMPLE CITY BLVD_Electrical WORKERS COMPENSATION DECLARATION 001 M DPW(12 9„ APPLICATION FOR ELECTRICAL PERMIT
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I he Eby a/hr,T that I have a certificate of consent to sell insure 76A
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(Sec 3800 Lab C)
Policy No Company FOR APPLICANT TO RLL IN JOB
PIX
Cor ifted copy is hereby lumahed New Residential Bldgs 8 Pools NO EACH FEE O♦
❑ 1 8 2 Fame Sq Ft ! S LOCALRY
Certified copy a with the county building Inspection H NEAREST
d,panment Multifemdy Sq Ft — CR0SS ST
Residential Swimming Poota ASSESSOR
Date Applicant MAP BOOK I PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS u0et w /�� /O• FpMEj griRE
i COMPENSATION INSURANCE _
(This eectlon need not be completed If the work Involved by the First _ -- L
permit b for one hundred dollars (1100)or lees) Total No Additional ADDRESS _ I
I certify that in the performance of the work lot which Ihls permit CRY ai TA w-
is Issued I shall not employ any person In any manner as
become subject to the Works rai Oompensa to Laws Lghimg Fixtures First 20 app
Total No Additional
_ ADDRESS
Data
— pi RESIDENTIAL APPLIANCES NOT OVER 3 HP
NO ICE TO AP (CANT e r makin rt ata o CITY Tel Na
Exemption,you should bet lett io the pikers C pensation OTHER APPLIANCES NOT OVER 3 HP _
provisions of the Labor Co you must fon Ith com y with suchERM'
Provisions or this permit shall be deemed revoked Power Apparatus 8 Large Appliances APPLICANT 1
LICENSED CONTRACTORS DECLARATION Sue 8 Type HP KW or KVAA ADDRESS
1 hereby'afhrm that I em licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and / 3 to 101nc1 CITY L Tel No ��•
Professions Code and my license is In full force and effect Over 10 to 60 Incl E ORQ/ }
^� ♦ Over SO to 100 Incl REG
MBER i a Com° �� IL
License,Number 5'2 G LIc Class�LL{L �r 100 DISTRICT NO —BY 0
— ) Servide A-99
Sw¢ap� MCC&P gpelboearde�_ / - %fC ¢
Cont,eclor ' Date — 1i rf11N 0'389CAm/-p' gar5/B00-Vt" 4; �� 0
I em exemp oder Sac — 400 1000 Amp Under 800 V VALIDATION W
Over 1000 Amp or Over 800 V FINAL d
B 8P C for this reason - BRANCH CIRCUIT FEES By Cn
to Z 15A o 20A 120V Lighting or Receipt Z
1 To 10 Branch Circuits
Signet 4t11 To 40 Branch Circuits
❑ pion for Reg MelVLE
t 15A 21YI 20BV To 27N�More& rciaa wBranch Circuits �ry
SINAMILY Temp Power Pole 8 Appunenences ACCT.i
I hereby affirm tthat I eME m exemptER )from the Contractor a License Law Sign with One Branch Circuit 3W7
for the following reason (Section 7031 S Business and Professions Additional Sign Branch Circuits
Code 1 ITEMS tJ
�y
F-1I as owner of the property will do the work and the structure Mac Conduit d Conductors _ TOTAL - 333 .81
Is not intended or offered for sale (Section 7044 Business Other(See Complete Fee Schedule)— nv
and Professions Code) ��1 wC�K 3K.98198i
�.L
CONSTRUCTION LENDING AGENCY 1v14AWE •130
I 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)
Civ C)
PLAN CHECKING FEE ODS-0001 12/28Ifr.
Lenders Nemo PERMIT ISSUING FEE 7239 1 AM 9:32
Lenders Address `
I certify that I have reed this application and under penalty of puqury state TOTAL FEE
that the above information is correct I agree to comply with all County
ordinances and Slate laws regulebrig Elecincel and hereby authorize
representatnss of thio County to lir uP mentioned property ,
for inspect nfpurpas r SEE REVERSE FOR EXPLANATORY LANGUAGE
LURE OFP WTE