HomeMy Public PortalAbout9564 BISBY ST_Electrical__ WORKER S'COMPEN$ATIONDECLARATION CEA 8 (2-BC4 APPLICATION FOR FLECYRICAi_ PERMIT
I hereby affirm that I have a certificate of convent to self COUNTY OF L09 ANGELES BUILDING AND SAFETY
Insure, or ■ certiftgate of Workers'Compensation Insurance,or
a certified copy thereof(Sec.3800,Lab.C.)
Polity NA -1- Company
State fund FOR APPLICANT TO FILL IN jOB
AQDRESS 9564 Bi'sby Street
New Resldentipl Bldgs.&.Pools EACH N9. FEE
4�ertlfied copy Is hereby furnished... 1 &'2-F4imlly.Sq. Ft.- i — 3 LOCALrrY Temple Cit
NEAREST
El Cer11f1ed copy Is filed with the tountY d�bud Inspection Mulil-family-Sq. 8T
q• Ft.
department. Rallderttiel Swimming Pools
OWNER OR Gilbert Roldan
Data3 16/84Applicant . Air-Tro, Inc..
MAIL
outlets Rec.—Light Sw. ADDRESS 9564 -Bisb Street
first 20
CERTIFICATE OF EXEMPTION,FROM WORKERS' TotQl No'.. AdditionalCITY Temple City TelNo. -575-,0292.
COMPENSATION INS,URANC& PLAN CHECK
(This section nQdd not be Completed feted if the work #R'otved APPLICANT Q
Llghtlnp20
#y the petmft b fox op@ hundred dollen (;100) or leas.) Additional
Fiat Addltionel ADDRESS v
(S
Totpl No.�— o
I cprtify that in the performance of the work for which'thL' CITY Tel No.
Fixed'Appliances Not Over 1 HP
permit Y issued, I shall not employ qtly person In any manner PERMIT A.l�-Trq, Inc. a
to as to become subject to the Workers;' Compensation Laws- Range_Heater_DA, PP ICANTto
Oven _ Dryer—W.M. T_' ADDRESS 1630 S. M rtle Ave., _
Data Applicant Top F _W.14.' - CITY Monrovia C3.T•I No.28 55
'
Hood _ Fanan —Other y �-
317
NOTICE TO APPLICANT: If, after making this Certificate of Dlsp. —Room Air Condom C O C
Exemption, you should become subject to' the Workbrs' REQ,NUMBER Cllr r r
Compensation provisions of the Labor Code,you must forth- Power Apperatos& Large Appliances DISTRtcT NO. PROCESSED BY
with comply with such provisions or this pertnit chap be
deemed revoked. Size&Type HP,KW,iCVA,or KVA
_ .Up tp 1 Incl FINAL
Our 1 to 10 Incl. DATE
LICENSED CONTRACTORS DECLARATION
Over 10io1i0 Incl.
( VALIDATION
I hereby 4ff(rm that I em,licensed under provttions of Cliapter Aver 60 to 100'1 ne.. FINAL
(commenctngwtth Section 7080) of Dtvfaion 3 of the Bust- Over 100 BY
neu'and Profeadom-Code, and my license is in full force and v
effect. Servltas
License Number 2 5 8 2 2 8 L,ic,Class C 10, 2 0,44 '0-200 tamp.Under 600 V 1
Air-Tro I& 3/16/84 201-1000 Amp.Uhder 600 V
a
Contctor Y e' Over 1000 Amp.or Over 600 V
HOME OWNER-BLJILD);R DECLARATION Temp. Poryer Pole&Appurtan&r ces
I hereby aMm that I am exempt from the Contractor's Sign with One Branth QIrcult 9 7 A
License Law for the followin recon Additional Sign Branch Clrcurts .
�' (Sectlop 7031.5, Bast-
nen-and Professions Code): ,#' o'o o o o 2
Mlsc.,Condults&Cbnductors
El I, as owner of the prop", will do the work and the Other JSea Complete Fee Schedule)— 2'°-o 2 5 5
structure is not intended or offered for tale (Section ' ;
7044, Business■ndProfeasions Code). ° o'o gra 5 063
CONSTRUCTION LENDING AGENCY +
I hereby affirm that there 1t a construction lending agency
for the performahce of the work for which thJs permit 4 I PERMIT FEF (Sub-Total)
m
Issued (Sec. 3097,Ctv.C.). t
Lender's Nae. PLAN CHECKING FEE (One-Fourth Permlt.Fee)
Lender's Address PERMIT ISSUING FEE 1� Q
I certify that I have read this appl,(catioh and state thdt the TOTAL FEF 0
above Information is correct.I agr�e to comply wtfh all County
ordinances and State laws regu sting Electrical wiring, and
hembthorise preventatives of County to enter upon
t o mets ed pro � SEE'REVERSE•FOR EXPLANATORY LANGUAGE
84
signature ofttee •