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Home My Public Portal About9050 GARIBALDI AVE_Electrical__ woRKER`S COMPENSATION DECLARATION 9 t7RW(12-91APPLICATION FOR ELECTRICAL PERMIT I herbby affirm that l hsve a cert1)7gate of cbnsent to self Insure, or a dertlflcato of Worker6 Compensation Insurance, or a certlfldd. COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV. cop;thereof(4ec. 3800 Lab. C.) Policy No._Company FOR APPL.IGIHT TO FU-L IN AJOBppgEgg ❑ Certf ad copy Is hereby fumlahed. New ReeldenM Bldgs.S NO. EACH FEE LOCAL TY ertu f1 ❑ aJ V Certified copy 4ed with rhe county buGdlrp Irnpectl1 8 2-FamCy,Sq.FL ZZNEAREST on Murtl femlry 3q.Ft — ST. t APP t Residential 8wtmming Pools ASSESSOR p �j Date MAP BOOK( CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets Rea_LJQM Sw. =ER OR COMPENSATION INSURANCE RRM NA1JE S �' First 20 (ThLe section need not be completed H the work Involved by the - ADORE38 permlt Is for one hundred dollars($1D0)or leas.) Total No. Addltlonal S I certify that In the performance of the work for which this permit CfTY ,V►40 Tet No. �-a►O L Is Issued, I shall not employ any person In any manner so as to PLAN CHECK become subject ffto the Workers'Compensation Laws. Llghdng Fb uree Rrat 20 APPLIGA7IT -31 �b,l q 5 L V e L)(j(L .J�l� Total No, Additlonal DadeAOD RESS NOTICE TO APPLICANT: If, after making this Certificate of RESIDENTIAL APPLIANCES NOT OVER 3 HP. CTTY TsL Na Exer�ptlon,.you should beoome subject to the Workers' Compenaatlon OTHER APPLIANCES NOT OVER 3 HP. provlslons of the Labor Code, you must forthwith comply with such PArlf Power Apparatus S Large Appllarwn provisions or this permit shall be deemed revoked. LICENSED CONTRACTORS DECLARATION S1ze S Type HP,KW,KVA,or KVAR- ADDRESS104�, roU e-r I hereby affirm that I am licensed under prbvfalons of Chapter B Over 3 to 10 Ind. �f (commencing with Seotlon 7000) of Division 3 of the Business and CITY Q��j/lC4 L T� NO �(��s�^ Profeaslons-Cods, and my license Is In full force and effect. Over 10 to 50 Incl.Over 100 DISTRICT N0.O� -f Over 60 to 100 Incl. REG- AP I�g c, 0�C-t� a G- BY O License Number s��9•�O Lb.Clare 1� � Q U 1 I Swvlcw Swbd.,MCC 8 Paneiboarde .�, 00 cc Co'.1'-wwtfC(,14,264 D �ere f q S 0-366 Amp.Under eco V DATE O ❑ I am exempt under Seo. 400-1000 Amp.Under 000 V Over 1000 Amp.or Over 600 VW Fi1Al_ d B.SP.C.for thIs reason BRANCH CIRCUIT FEES BY42�� (D Dads: 15 161,or 20A, 12OV,Ughbng or ReceQt. Z 1 To 10 Branch Clrcutte ftna 1fe 11 To 40 Branch CtcuRs 41Or Ir{ore Branch Circuits F-1for Reg.MatnL Elect. 1K 20.r,208V To2T/V Br.Ck*cub SINGLE FAMILY Temp.Power Pole S Appurtenancee i HOME OWNER BUILDER DECLARATION S�with Or*Branch Ctrcuh 9 1 .r I hereby affirm that I am exempt from the Contractor's IJcenee Law y � for the following reason (Section 7031.6, Business and Professions Addttlonal Sign Branch Clroutts 3303 LT7p.f`' Cpde): ❑ I, as owner of the property,will do the work and the structure Mlao.Conduits 8 Conduoton 1 I!EMS Is not Intended or offered for sale (Section 7044, Business Other(See CompFete Fee Schedule) ' TOTAL 249 - 78 end Professions Code). f 78 CONSTRUCTION LENDING AGENCY FL� v 249. I hereby affirm that there Is a construction lending agency for the NlFfa GE .00 performance of the work for which this permit Is Issued (Sec. 3097, PERMIT FEE (Sub-Totp4 Cly. C.) PLAN CHECKING FEE vu�y tni -, i 1 Lendet'e Name LeJL!C1'{�Ar 1 ,�� 6! K. PERMIT ISSUING FEE �I 9i-45 I PM12:11 Lender's Address �� I] TOTAL FEE I oertify that I have read this appficatlon and under penalty of purjury state r that the above InfornrLeon Is correct. I agree to comply with all County ordrunose and 8rsde iswro reg ng sec rival wtring,end hereby audwrtze repreeentalfvee of County enter upon the abov*-merrtloned property 'Dr Ir>,apeatf SEE REVERSE FOR EXPLANATORY LJKJJC+t1A13E -=L-, , aaiNATL*U- ATE �woRl�'s COMPENSATION pECLAAATION AAM DPW c,2-91, APPLICATION FOR ELECTRICAL PERMIT I hereby attlrm that I have a certificate of consent to self Insure, or a oertlflcate of Worker's Compensation Insuranoe, or a certifled COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV. copy thereof(Seo. 3$00 1-0.C.) ❑�No. Company PGR APPLIGINTTOFILL II X9050 Garibaldi, Tem le Cit CerNed copy 1:srtial hereby furnished. New RaslderBldgs.&Pools NO. EACH FEE LOCALITY ❑ CertMed copy Ia sled with the county bufld]ng Inepeatfon 1 2 Farnly, T — $ $ NEAREST Temple City deparbnent M,dn-fnrnfy Sq.FL — caosa ST. Hart D99 Applicant Reeldentisl Swimming Pools mASSESSOR AP Boor( 5384 P,.,,015 PARCa 015 CERTIFICATE OFBCEMPT ON FROM WORKF-W Off:Rec._ Svv. Fl Fw OWNER OR L11 Garibaldi Trust COMPENSATIQN INSURANCE (This section need not be completed H the work Involved by the Tatal No. Addltlonal Arwt 2D AJL 88 PO Box 2313 permtt In for one hundred dollars($100)or lees.) I certify that In the performance of the work for wh(ch this permit CITY San Gabriel CAT1'91778 le Issued, I shall not employ any person In any manner so as to PLlN qfq� beoome subject to the W6rkers'Compensati Ll9hnG Fbchrrea Flrat 20 APPucAxr Owner Total No. Adcltonel oats Tl-29-94ADOREss ame App{Icant RESIDENTAL APPLIANCES NOT OVER 3 HP. le NOTICE TO APPLICANT: If, atter ma Ing CertIfIcate of CITY Same TOL No. Exemption,you should beoome subject to the Workers' Compensation OTHER APPLIANCES NOT OVER 3 HP. provisions of the Labor Code, you must forthwith oomply with such � Sgt provisions or this permlt shall be deemed revoked. Power A`pparaWs S Large Applfences LICENS1EDtOfTAACTORS DECLARATION Stze✓f Type HP,KW,KVA,or KVAR ADDRESS Sane I hereby affirm that I am licensed under provisions of Chapter 9 Ove"to 10 Incl. (oommenoing with Section 7000) of Division 3 of the Business and CITY Same Td No Profeasfone,Code,and my license Is In full force and effect. Over 10 to 50 Ind. UCIEN E OR } Over 60 to 100 Ind. REG.NUMBER Ote'w d Over 100 DOTRJCT NO. BY S License Number Llo.Ctaee T Services,Swbd.,MCC a Ponelboerds Contractor Date 0-399 Amp.Under 600 V F9 NA El 400-1000 Amp.Under 800 V G V I am exempt under Sec: Over 1000 Amp.or Over 600 V FNAL ` v VALIDAMN LU B.BP.C.for this reasonBY / C/)BRANCIi CIRCUIT FEES Dote: 15A,.or 20A,120V,Lighting or Recept 1 Z 1 To 10 Branch Cfradts hh!� T rs 11 To 40 Brash Brah Ctarfis AN 1 .r 41 Or More Branch Clits ❑ Exemption for Flag.Malrrt.E wt 15A,2D4,2WV To 277V Br.Crouka j T 67.6._1 SINGLE FAMILY Temp.Power Poie h Appurtenarw �7�tw 1 ITEM [_I k7 HOME OWNER-BUILDER DECLARATION Ston with One Branch Circuit _ � I hereby affirm that I am exempt from the Contractor's Lloenee Law TOTAL ff for the following reason (Section 7031.6, Buslneas and Profemmlons Addit}onal Slgn Branch Circuits Code): C:�ECFI 67.65 ® I,as owner of the property,will do the work and the structure Misc.Conduits A Conductors �VMGE ' is net Intended or offered for male (Section 7044, Business Other(See Complete Fee Sctt6duk�) , W and Professions Code). CONSTRUCTION LENDING AGENCY ) L4JU t 1 f S4 I hereby affirm that there Is a construction lending agency for the 79 1 [J performance of the work for which this permit Is Issued (Seo. 3097, PERMIT FEE r (Sub 1-Tota]) / f 71� PM Q-'32 Ctv.C.) NONE PLAN CHECKING FEE Lender's Nemo PERMIT ISSUING FEE L� Lender',Address.NOIR I tartly that I haus reed this appflcation and under penalty of perjury state TOTAL FEF (0 dud the above Infomudion Is correct. I agree to comply with all County lei ordnanoes and State laws regulating Electrical wiring,and hereby authortre rspreeentaifves of this County to enter upon the above-mentioned pJj }or SEE REVERSE FOR EXPLANATORY LANGUAGE 11-29-94 :;tIJ DATE �) � v