HomeMy Public PortalAbout8849 ELM AVE_Electrical__ NORM READY FOR, INSPECTION JOB 8245
WORKERS'COMPENSATION DECLARATION _ to/Bt APPUC�G�I�DOo H FOR ELEC Y ° D CAL P °�vli N
= I herebb CE-806y affirm that I have a certificate of consent To self CE-806G ,
insure, or a certificate-of Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING ARID SAFETY
or a certified co thereof (Sec. 3800, Lab. C.) 4 !
>#3��002 STATE COMP
Policy No. Company FOR APPLICANT TO FILL IN JOB
ADDRESS8849 ELM AVE
Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE
® Certified copy is filed with the county building inspec- 1 & 2-Family, Sq. Ft. $ — $ LOCALITY TEMPLE CITY
tion department. Multi-family Sq. Ft. — 'NEAREST
CROSS ST. ROSEBMD BLVD
7/21/83 TR1GiS BROS ELECT. Residential.Swimming Pools OWNER OR
Date ApplicC. 175 j 5 FIRM NAME- IMS FRYPIIRGER
CERTIFICATE OF'EXEMPTION,FROM WORKERS' Outlets: Rec Light Sw. MAIL 8849 BI AV
COMPENSATION INSURANCE ADDRESS
First 20 TY
(This section need not be completed if the work involved by Total No. Additional CITY'j'$]�j�E CI .- - Tel. No. 285-1301
the permit is for one hundred dollars($100)or less.)
I certify.that•in the performance of the work for which this PLAN CHECK
- Y; P APPLICANT
permit 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
Total No. Additional
CITY Tel.- No.
Date Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT GIBBS EROS SECT CO INC.
Exemption, you should become subject to .the Workers' Range_ Heater_D.W. —
Compensation provisions of the Labor Code, you must forth- Oven _ Dryer — W.M.— ADDRESS 1754- N- BRAIN STREET
with comply with such provisions or this permit shall be Top _ FAU —W.H. —
deemed revoked. CITYLQS -ANGELES Tel. No225-5945
LICENSED CONTRACTORS DECLARATION Hood _ Fan _Other—
LICENSE_ Room Air Cond. — LICENSE OR 169324• class.C—IO
I hereby affirm that I am licensed under provisions of Chapter 9 REG. NUMBER
(commencing with Section.7000) of Division 3 of the Business DISTRICT NO.. FIR D BY
and Professions Code,and�my license is in full force and effect. Power Apparatus& Large Appliances d
Size &Type HP, KW, KVA, or KVAR �F O
License Number 169324 Lic. Class C-10 FINAL V
GIBBS BROS ELECT INC .. 4-4-84, to 1 Incl. DATE ^! ^��`
Over 1 to VALIDATION.J VALIDATIOO
Over
Contractor Date Over 10 to 50 Incl.
FINAL �
.. - u
I am exempt under SeC. Over 50 to 100 Inc. BY LU
IL
B.&P.C. for this reason Over 100
Date: Services, Swbd., MCC & Panelboards D
0 -200 Amp. Under 600 V
Signature 201 1000 Amp. Under 600 V
Over 1000 Amp. or Over 600 V
Exemption for Reg. Maint. Elect. Q rJ b.A
SINGLE FAMILY Temp. Power-Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit #Io o ° o o2 '
I hereby affirm that lam exempt from the Contractor's License Additional Sign Branch Circuits
Law for the following reason (Section,7031.5, Business and 2 0 1 1.25
Professions Code):
I, as owner of the.property,'will do the work and the Misc. Conduits& Conductors a 0 c 1.1.2 5,
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ D
7044, Business and Professions Code)'. 7,2 9 8;3
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 PERMIT FEE (Sub-Total) e 5
(Sec. 3097, Civ. C.).'
PLAN CHECKING FEE
Lender's Name 70
PERMIT ISSUING FEE
Lender's Address
0
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
ordi antes and State laws regulating Electrical wiring, and
her ' y authorize representatives of this County to enter upon
th hove-mention d roperty for.inspection purposes.
c SEE REVERSE FOR EXPLANATORY LANGUAGE
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