HomeMy Public PortalAbout5728 A-ETEMPLE CITY BLVD_Electrical (2) i - 1N9RKERS COMPENSATION DECLARATION 711"03 10/91 APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm Mat I have s certifM of consent to self ueme v CE 9060
o a certificate of Worker4 Campensaaon Insurance or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof(Sec 3800 Lab C) • ..yy��� ! /
P09uY mperry Ur FOR APPLICANT TO RLL IN i =ESS
❑ feed copy is her6by furnished V New Residential BWOs d Pods EACH NO FEE 22111,
Cerehe5ie
bore Ino mrmpechOn 1 8 2-Fermly S0 Ft $ = LOCALITY CIT
t ResideMuth-1mdy S i Ft CROSS 3T
Date Resdentuil Swimming s OWNER OR��, �''� '7� � 'FlR1A RTIFRKERS Outlets Rec j�U Lght �JL Sw iQL \� .rr r �'v g` AIJOFiESs
Fi It 20
(ThIs sect need n e competed d the work ewolved by the �L d _ CRY \/ " t No
I»rrtdt I one rdred dollars(5100)or less) Total No Additional ,V 2
I cam the performance of the work for which this permit PLAN CHECK,
k 1 shell rot employ any person in any manner so as to APPLICANT
become subled to the Workers Compensation laws Lighting Fixture First 20 ADDRESS
I Tote,No 45-0 ACdilcnal _ CffY T No ]y
Date Applicam Fixed Apple a Not Over 1 HP
NOTICE TO, APPLICANT II a}ter making
MIs CertHloato of PERMITv Exemption you should become subleot to the Workers Compensation _Range Heater DW APPLICANT
prisons of the Labor Code you must forthwith comply With such Oven Dryer � Aim ADDRESS P v
pxovts ons or this permit shall be deemed revoked Top yy7 FAU WH _
LICENSED CONTRACTORS DECLARATION Hood `1_Fan Other_ 0 CITY Tel No
I heieby affirm that I am licensed under provrsons of Chapter 0 LICENSE OR
(commenc,mg With Sechon 7000) of Division 3 of the Business and Dip Roos �� REG NUMBER
Professions Code'end rtry license is m full torte and eked power Apparatus 8 Large Applmrces
S¢e d Type HP KW KVA or KVAR ✓ VV O
License Nu I qA Lit Close Up to i Ind FINAL C�
Contractor n CLf t:— Date V _ Over 1 ' Incl DAA ^3 —9� VALIDATION _ Q
Over 10 t to 5 60 Ind FINAL
❑ I am exempt under Sec Over 50 to 100 Inc B1'
B&PC for on this reasOyer 100 (� N
Sernces Swbd MCC 8 Panolboards .Z+
Date 0- 200 Amp Under 900 V Q '
Signature 201 - 1000 Amp Under 600 V -
❑ Over 1000 Amp or Over 600 V
Exemption lor Rep Mount Elect
SINGLE FAMILY Tamp Power Pole 8 Appurtenances
HOME OWNER-BUILDER DECLARATION Sign With One Branch Circuit 2
I heri eHmm that I am exempt from the Contractors Lcenme Law Ay.�/v�T ay
for the fdbwmg reason es
(Section 7031 5 Business and Prolesscro Additional Sign Branch Orcura IWMI.f
Cade) 1 3307 408.00
ElMisc Conduas 8 Cocluctors 1 ITQ15
as owner d the property unit do the work and the structure Other(See Complete Fee Schedule) ,
is not intended or offered for sale (Section 7044 Business a T��y�v ¢O�-OO
and Profess ms Code)
CONSTRUCTION LENDING AGENCY - - MLM - 4W.O(l
I hereby affirm that there is a construction lending agency for the
perfomiarx;e of the work for which this permit u meted(Sec 3087, PERMIT FEE (Sub-Total) - {.TVYY4i .00
Cry C)
PLAN CHECKING FEE _ - -
Lerdera Nene 0000-0001 4/19/96
PERMR ISSUING FEE
Landers Address 6 0187 1 An 8,:26
1 oerhfy that I have read this application and state that the above TOTAL FEE '
iMormatxm m correct I agree to pomp/ with ell Count' ordinances -
eritl Ste laws ra P lab Electrical Wring and hereby auttx=e
repro t s Mm N to anter upon the -mentioned
" -
rposes ^/I-'fin SEE REVERSE FOR EXPLANATORY LANGUAGE
ra d Pernittee