HomeMy Public PortalAbout5717-5719TEMPLE CITY BLVD_Electrical (2) WORKCOMPENSATION DECLARATION 7 ,aDRV(,2 a„ APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm thatt I havehave a certificate o/ consent to self insure
or a cenrticate of Worker a Compensation Insurance or a certified COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV
copy thereof(Sec 13800 Lab,C)
Policy No Company FOR APPUCANT TO RLL IN
❑ Certified copy Is hereby furnished New Residential Bldgs &Pools NO EACH FEE ADDRESS
❑ $ = LOCALITY•Cemued copy is filed with the county building Inspection 1&2 Family Sq FI NEAREST
department Multifamily Sq Ft — CROSS ST
Residential Swimming Poole - ASSFSSOq
Data Applicant MAP BOOKSSOR PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS r7 O OWNER OR
COMPENSATION INSURANCE s —LIGM w — N NAME -
(This section need not be completed if the work Involved by the First 20 MAJU
permit Is 16r one hundred dollars(8100)or lop) Taal No Addnional ADDRESS Y/
I certify that in the performance of the work for which this permit CITY Tel No
Is issued I shell not employ any person in any manner e s to PLAN CHECK
become subject to the Workers Compansabon wWCn.t,.�f
Lighting Fixtures Fret 20 APPUICAPR
Total No Additional
ADDRESS
Date hcant
NOTC TO APPLI ANT Ifs ma mg RESIDENTIAL APPLIANCES NOT OVER 3HP CITY — Tel No
Exemption you should become a ct to the W aOTHER APPLIANCESNOT OVER 3 HP
provisions of the Labor C ou must forlhw h comply with suchD
provisions or this permit shall be deemed revoked Power Apparatus&Large Appliances- LICANT ,
LICENSED CONTRACTORS DECLARATION Size&Type HP KW KVA or KVAR ADDRESS
h
hereby affirm that I em licensed7000) under provisions of Chapter d Over 3 to 10 Incl �/ IT 40
Professions
de Section 7000) of Division 3 of the effect
Business end CT' Tel
Prolessione Code and my license is in full force and effect Over 10 toSOW 50 Incl LICENSE OR }
Over SOW 1001nc1 REG NUMBER 2 d CL
Over 100 - ` DISTRICT NO ISD BY U
License Number 4c Clessll�y
7 $ay Ce9 SWbd SCC LIer D FINAL
Gonaeclor 19 /1-`Ld '7f/ C/ 'ay0 -L-P� ride �O DATE H
1 am exempt nder Sec 400 1000 Amp Under 800 V ���� �9 VALIDATION W
Ovar 1000 Amp or Over 800 V FINAL / d
B&P C far this reason BRANCH CIRCUIT FEES BY CD
to 15A or 20A 120V 4ghbng or Recept z
1 To 10 Branch Circuit
Sgntuuro 11 To 40 Branch Circuit .T
❑ Rag Mel Elect 15A 20.4 20BV To 277VO More&ra ul� L
Ex ion fo
SINGLE FAMILY Temp Power Pole&Appurtenances ACCT.A
HOME OWNER BUILDER DECLARATION Sign with One Branch Circuit3M7 _- �'��
I hereby affirm that I em exempt from the Contractor s License Law
for the following reason (Section 7031 5 Business and Professions Additional Sign Branch Circuits �Nr�
Code) 1 I t G 1,7
❑ 1 as owner of the property will do the work and the structure Misc Conduits&Conductors __TOTAL 325.23
is not intended or offered for sale (Section 7044 Business Other(See Complete Fee Schedule)
and Professions Code) VyyF�AECK 325.23
CONSTRUCTION LENDING AGENCY - 4FNGE •�
I hereby affirm that there is a construction lending agency for the
performance of the work for which this permit is Issued (Sec 3087 PERMIT FEE (Sub TOla1) V 1 {^' `9�
Civ C) 12
PLAN CHECKING FEE
Lenders Name 7238 1 Aft 4:332
PERMIT ISSUING FEE
Lentler a Address ^
I Certify that I have read this application and under penalty of pudury state TOTAL FEE
that the above mformation is correct I agree to comply with all County
ortlinariose and State laws regulaung ElfactUcta wining and hereby authonze
repreaentativea of thio Conn to ante a above-mentioned property
for inspsoff9po1purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
E .
/ p � DATE