HomeMy Public PortalAbout5753TEMPLE CITY BLVD_Electrical WORKER S'COMPENSATIONDECLARATION 768663 APPLICATION FOR ELECTRICAL PERMIT
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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.)
Policy No. Company FOR APPLICANT TO FILL IN JOB
ADDRESS
New Residential Bldgs.&Pools EACH N0. FEE
Certified copy is hereby furnished. 1 &2-Family,Sq.Ft. $ — $ LOCALITY _
F1 Certified copy is filed with the count buildin Multi-family Sq. Ft. NEAREST
y g inspection CROSS ST
department. Residential Swimming Pools OWNER OR
f, FIRM NAME
Date Applicant Outlets: Red-1 Light S Sw20 lid ADDRESS ��/ X/• LEM^gF. CrT �Cc�
20
CERTIFICATE OF EXEMPTION FROM WORKERS' Total No.� L Additional CITY c� Tel No. S�
COMPENSATION INSURANCE PLAN CHECK d
(This section need not be completed if the work involved APPLICANTOil S .
by the permit is for one hundred dollars ($100) or less.) Lighting Fixtures First o ADDRESS
Total No. Additional.
I certify that in the performance of the work for which thisCITY Tel No. O'
permit is issued, I shall not em Fixed Appliances Not Over 1 HP
p employ y an y person in any manner PERMIT �
so as to become subject to the Workers'Compensation Laws. "
Range_Heater_D.W. _ APPLICANT F� /� "7/Kr Z W
Oven Dryer_W.M._ ADDRESS
S-
%
Date Applicant Top _ FAU _W.H.._ 7`� � C�
Hood Fan _Other_ CITY +I� Tel.
NOTICE TO APPLICANT: If, after making this Certificate of Disp. _Room Air Cond— LICENSE OR
Exemption,/ you should become subject to the Workers' I REG.NUMBER Class
Compensation provisions of the Labor Code, you must forth- Power Apparatus&Large Appliances DISTRICT NO. P D BY
with comply with such provisions or this permit shall be
deemed revoked. Size&Type HP,KW,KVA,or KVAR
Up to 1 Incl. (�
FINAL
LICENSED CONTRACTORS DECLARATION \Over 1 to 10 Incl. DATE!J �j VALIDATION
Over 10 to 50 Incl. G
I hereby affirm that I am licensed under provisions of Chapter Over 50-to 100 Inc. FINA
9 (commencing with Section 7000)of Division 3 of the Husi- Over 100 BY
ness and Professions Code,'and my license is in full force and
effect. Services
0-200 Amp.Under 600 V
License Number- Lic.Class 201-1000 Amp.Under 600 V
Contractor 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
ness and Professions Code): ' 0 1' Q'1 A
Misc.Conduits&Conductors
2 I, as owner of the property, will do the.work and the Other(See Complete Fee Schedule)— # o'0 a o c2
structure is not intended or offered for sale (Section
7044,Business and Professions Code). 2 0 - 31.80
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction•lending agency �
for the performance of the work for which this o 0 0 3�,8 0 F-
p permit'is
issued(Sec.3097,civ.C.). PERMIT FEE (Sub-Total) 0609-81
-
Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee)
Lender's Address I 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 above-mentioned property or inspection purposes.
SEE'REVERSE FOR EXPLANATORY LANGUAGE
1
Signature of Permittee Date i fl