HomeMy Public PortalAbout5729TEMPLE CITY BLVD_Electrical (2) aVURKERS'COMPENSATIONDECLARATION cE-806 APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY
insure,or a certificate of Workers'Compensation Insurance,or.
a certified copy thereof(Sec.3800,Lab.C.).
FOR APPLICANT TO FILL IN JOB r� ✓
Policy No. Company New Residential Bldgs.&Pools EACH NO. FEE ADDRESS S72 1WR ur out?
Certified copy is hereby furnished. I &2-Family,Sq.Ft. $ — $ LOCALITY ' empty C
Certified copy is filed with.the count building Multi-family Sq. Ft. O CROSS ST Z�,Y `' -
p y g inspection Residential Swimming Pools
department. OWNER OR - v/ C-0401 :1"10 14
(� .
Date Applicant MAIM NAME IAV �V
Outlets: Rec� Ligh Sw. ' 0,14 J 4/� G4Z
First 20 ADDRESS
CERTIFICATE OF EXEMPTION FROM WORKERS' Total No: Additional CITY 1EMEL,6 G'n -Tel No. �$S�]�2 >_COMPENSATION INSURANCE fL
� PLAN CHECK�/'�,.� 't .r 0
APPLICANT t ro'tl u� ro C V
Ms section need not be completed if the work involved ' Lighting Fixtures First 20 ADDRESS
y the permit is for one hundred dollars ($100) or less.) 6�1, (2OL(? VI�GS
Additional
Total.No.44 O
I certify that in the performance of the work for which this CITY 1VCk0'I Tel No.Q-C(�o-OZI•g, H
permit 4s issued I shall not employ an person in an manner Fixed Appliances No ver 1 HP V
P � P Y Y P Y PERMIT 1�i�,ea,�y W
so as to become subject to the Workers'Compensation Laws. Range Heat ? D.W. APPLICANT -JA 0, .V- 1n d
Cn
Oven _ Dr r a W.M.. ADDRESS [ t z
Date./6-6 Applicant' ° ed
Top U -LW.H:._ U
Hood Fan +Other_ CITY 1 Ar Tel No.444-6•-6- (A
NOTICE.TO APPLICANT: If, after making this Certificate o Disp. Room Air Cond— LICENSE OR
Exemption, you should become subject to the Workers" REG.NUMBER S?f� . Class
Compensation provisions of the Labor Code,you must forth- Power Apparatus&Large Appliances WS.TRICT N.O. PRO'C SSED BY
with comply with such piovisions or this '.permit shall be
deemed revoked. Size&Type HP,KW,KVA,or KVAR � V
Up to 1 Incl.
FINAL -
Over 1 to 10 Incl. DATE
LICENSED CONTRACTORS DECLARATION VALIDATION
Over 10 to 50 Incl.
I hereby-affirm that I.am licensed under provisions of Chapter ' ' Over 50 to 100 Inc.
BY AL
9 (commencing with Section 2000)of Division 3•of the Busi= Over 100 d--f`(""t-,'.a.�
ness and Professions.Code, and my license is In full force and
effect. Services
License Number- Lic.Class- F> 0-200 Amp.Under 600 V
�� 201-1000 Amp.Under 600 y
ContractorJ"A 1lJ9 4 Date // �� Over 1000 Amp.or Over 600 V
HOME OWNER-BUILDER DECLARATION - Temp.Power Pole&Appurtenances
I hereby affirm that I am exempt from the .Contractor's Sign with One Branch Circuit
License .Law for the following reason (Section 7031.5, Busi- Additional Sign Branch Circuits i
ness and Professions Code): I z 2[I.76 A
Misc.Conduits&Conductors #'0 0 0 0 2
'I, as owner of the property, will do the work and the Other(See Complete Fee Schedule)—
0
structure is not intended or offered for sale (Section
7044,Business and Professions Code). 2.- 1 0.050
CONSTRUCTION LENDING.AGENCY '
I hereby affirm that. there is a construction lending agency r ° ° 1 0 G i G 63
for the performance of the work fo which this permit is PERMIT FEE (Sub-Total)
issued(Sec.3097,Civ. ). L74,2
Lender's Name 1 _ PLAN CHECKING FEE (One-Fourth Permit Fee)
Lender's Address /l ��rV
PERMIT ISSUING.FEE
I certify that I have.read this application and state that the TOTAL FEE.
above information is correct.'I agree to comply with all County
ordinances and State laws regulating Electrical wiring, and
hereby authorize representatives of this County to enter upon '
the ab ve-mentioned propertyfor inspection purposes. ` SEE'REVERSE FOR.EXPLANATORY LANGUAGE
9/7,91F0
!Sig f�erm� 6e Date