HomeMy Public PortalAbout5841TEMPLE CITY BLVD_Electrical (2) WORKER'S COMPENSATION DECLARATION 9 DPW 9/89 APPLICATION FOR ELECTRICAL PERMIT
76A66
I hereby affirm that I have a certificate of consent to self insure. 76A663
or a certificate of Worker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV.
copy thereof(Sec.3800 Lab.C.)
" �� p y_^t FOR APPLICANT TO FILL IN JUB
Policy No. ` "ro' man rtii•rs rrn �r is
F-1
ADDRESS C'`
Certified copy is hereby furnished. New Residential Bldgs.&Pools EACH NO. FEE
❑ 1 &2-Family,Sq.Ft. $ $ LOCALITY
—
Certified copy is filed with the county building inspection NEAREST
department. - Multi-family Sq.Ft. — CROSS ST.
Date Applicant Residential Swimming Pools ASSESSOR
MAP BOOK PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec.—Light Sw. FlWN R OR 'y
COMPENSATION INSURANCE RM First 20 CJ'lly OF T
MQU CITY
(This section need not be completed if the work involved by the MAIL
permit is for one hundred dollars($100)or less.)
Total No. Additional ADDRESS 9701 LASS
DR-
I certify that in the performance of the work for which this permit CITY TO-:LE My Tel.No.
is issued, I shall not employ any person in any manner so as to PLAN CHECK
become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 APPLICANT
Total No. Additional
ADDRESS
Date Applicant 15 OR 20A,120V BRANCH CIRCUITS
NOTICE TO APPLICANT: If, after making this Certificate of CITY Tel.No.
Exemption,you should become subject to the Workers'Compensation 1 TO 10 INCLUSIVE EACH
provisions of the Labor Code, you must forthwith comply with such 11 TO 40 INCLUSIVE EACH gppM�Aj W ELEM. Co. }
provisions or this permit shall be deemed revoked. 41 OR MORE BRANCH CIRCUITS EACH
LICENSED CONTRACTORS DECLARATION ADDRESS
I hereby affirm that I am licensed under provisions of Chapter 9 15 OR 20A,208V TO 277V LIGHTING EACH 319 SM DIe QW. AD. 0
(commencing with Section 7000) of Division 3 of the Business and CITY I N . V
Professions Code,and my license is in full force and effect. RESIDENTIAL APPLIANCES UP TO 3HP LICENSE OR ygg J_
Power Apparatus&Large Appliances REG.NUMBER 75339 Class.
LL
[ ~" '� i��l 11 Size&Type HP,KW,KVA,or KVAR DISTRICT NO. PROCESSED BY Q
License Number_LLf 5:1 ,s LiC.Class
Up to 3 Incl. Q
W11/,, ., Over 3 to 10 Incl. FINAL cc
Contractor cv f1_1"e_ t_ L-14 Date t3�f 22 Over 10 to 50 Incl. DATE
❑ I am exempt under Sec. Over 50 to 100 Incl. 7 VALIDATION
AL
B.&P.C.for this reason
Over 100 BYAL
W
Services,Swbd.,MCC&Panelboards
Date: 0-200 Amp.Under 600 V r
Signature 201 -1000 Amp.Under 600 V
❑ �: an.��
Exemption for Reg.Maint.Elect. Over 1000 Amp.or Over 600 V
SINGLE FAMILY Temp.Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License Law
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits
Code):
❑ I, as owner of the property,will do the work and the structure Misc.Conduits&Conductors
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule)
and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the
performance of the work for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total)
Civ.C.)
PLAN CHECKING FEE A '
Lender's Name
PERMIT ISSUING FEE
Lender's Address
I certify that i have read this application and state that the above TOTAL FEE
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 for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE OF APPLICANT OR AGENT DATE