HomeMy Public PortalAbout5753TEMPLE CITY BLVD_Electrical (2) osl WORKERS'COMPENSATION DECLARATION CE-80663
E 806G '°'B' APPLOCMON FOR ELECTRICAL PERMIT
•4.1"reby ffrm that I have a certificate of consent to self insure,
or a certificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof,(.Sec.3800,Lab.C.)
Policy No. Company FOR APPLICANT TO FILL IN JOB
❑ Certified copy is hereby furnished. New Residential Bldgs.&Pools
EACH NO. FEE ADDRESS C r�'
❑ Certified copy is filed with the county building inspection 1 &2-Family,Sq.Ft. $ — $ LOCALITY
department. Multi-family Sq.Ft. — NEAREST'
CROSS.ST. rit% E IT A77VV
Date Applicant Residential Swimming Pools OWNER OR d
FIRM NAME A MAJ? •2—
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec.—Light_Sw.— MAIL
COMPENSATION INSURANCE
First 20 ADDRESS
(This section need not be completed It the work involved by the CITY Tel.No.
permit is for one.hundred dollars($100)or less.) Total No. _ Additional L C / �`-1;
I certify that in the performance of the work for which this p@rmit PLAN CHECK '
' APPLICANT
is.issued, I shall not employ any person in.any manner.-so as to
become subject.to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS
Additional
• Total No. CITY Tel.No.
Date ApplicantFized Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, after making this Certificate., of; APPLICANT
Exemption,you should become subject to.the Workers'.Compensation Range_ Heater_ D.W.
provisions of,the Labor Code,you must forthwith comply with such Oven Dryer_ W.M._ ADDRESS
provisions or this permit shall be deemed.revoked. Top. FAU W.H. _
LICENSED CONTRACTORS DECLARATION. Hood — Fan Other_ CITY Tel.No.
I hereby affirm that I am licensed under provisions of Chapter 9 u.CENSE OR
(commencing with Section 7000)of Division 3 bf the Business and Disp. — Room Air Cond. REG;.NUMBER: Class•
Professions Code,and my license is in'full force and effect. - Power.Apparetus&.•Large Appliances DISTRICT NO. P SED BY
Size i;'Type HP;KW,KVA,or-KVAR �(/ ^'
License Number. Lic.Class Up to 1 Incl. FINAL C�
Over. 1 to 101ncl. DATE 6 — VALIDATION
Contractor 'Date Over 10 to 50 Inc]. • Q
❑
FINAL. W .I am'exempt under Sec.. Over 50 to 100 Inc. B.Y
B.&P.C.for this reason Over 100 N1
Services,SAb .,MCC&Panelboards �.
Date:. 0 0 mp.Under 600 V d
Signature' 201•- 1000 Amp.Under 600 V
Over 1000 Amp.or Over 600 V
❑. Exemption for Reg..Maint.Elect: r ,
SINGLE FAMILY Temp.Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit n s
I hereby affirm that I am exembt from the Contractor's License Law (Jti•.;
for the following reason(Section 7031.5,Business and Professions Additional Sign Branch Circuits M _
Code): -=i= ZiV _.E
Misc.Conduits&Conductors
LPJ 1,as owner of the property,will do the work and the structure " E S
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule)
and Professions Code). pool.. 59.+_5.._.
CONSTRUCTION LENDING AGENCY ••f a
I hereby affirm-that there.is a construction lending agency for the
performance of the work fo'r.which this permit is issued(Sec..309.7, PERMIT FEE ' (Sub=Total). CPI'1N G 'I-•I-
Civ.C.).
PLAN CHECKING FEE. :
Lender's Name ��/_ ii j`�3-" 1_tL i
PERMIT ISSUING FEE. 7-
Lender's Address (6-11 4 A 14:17
I certify that I have read this application and state that the above TOTAL FEE. 673"
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
Z-mro rty for inspection pur ossa.. / SEE REVERSE FOR EXPLANATORY LANGUAGE
ignature of Permittee Date