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Home My Public Portal About8838 LAS TUNAS DR_Electrical__ WORKERS' COMPENSATION DECLARATION 76A66310,81 APPLICATION FOR ELECTRICAL PERMIT I hereby affirm that I have o ceUCE-806G consent to self CE-8066 insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY /.-//p or a certified copy thereof (Sec 3800, Lab. C.) O cyNo.000O819O16)%pony Calif. Casualty FOR APPLICANT TO FILL IN JOB Certified copy is hereby furnished. New Residential Bldgs. 8 Pools EACH NO. FEE ADDRESS TempleCity Sheriffs Station Certified copy is filed with the myb ing inspec. I & 2-Family, Sq. Ft. $ $ LOCALITY8838 F I Qs; Tunas Dr jample ity tion d par ent. Multi-family Sq. Ft. — NEAREST CROSS ST. Encinitas Avenue Dote � Residential Swimming Pools Applicant OWNER OR RMNAME Temple City Sheriffs Sta. CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec_Light_Sw. ''BAIL 8838 E. Las Tunas Drive COMPENSATION INSURANCE First 20 ADDRESS (This section need not be completed if the work involved by Total No. the permit is for one hundred dollars($100)or less.) Additional CIT Tem le City CA Tel. No. I certify that in the performance of the work for which this PLAN CHECK 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 Hairell Electric CO. s 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 2316 W. Victory Blvd. with comply with such provisions or this permit shall be Top — FAU —W.H. — deemed revoked. CITY Tel. N LICENSED CONTRACTORS DECLARATION Hood — Fon _ Other_ — — 1 . LICENSE Disp. Room Air Cond. REG. I hereby affirm that I am licensed under provisions of Chapter 9 REG. NUMBER 364386 Class. C-lO (commencing with Section 7000) of Division 3 of the Business DISTRICT NO. PROCESSED BY Cl- and Professions Code,and my license is in full force and effect. Power Apparatus 8 Large Appliances O. Size &Type HP, KW, KVA, or KVARQ License Number 364386 Lie Class C-10 _ 1 Up to I Incl, CE, 1YG FINAL - M Q Over 1 to 10 Incl. DATE y DATION 0' Contractor Hairell Elec. Date ✓ Over 70 to 50 Incl. FIN W ❑ 1 am exempt under Sec Over 50 to 100 Inc. BY / d' Over 100 [� z B.&P.C. for this reason _ Date: Services, MCC 8 Pa nelboards g 9 5 5,6 A 0 -2000 Amp. Under 600 V Signature 201 - 1000 Amp. Under 600 V e e e e Is 'L ❑ Over 1000 Amp. or Over 600 V Exemption for Reg. Maint. Elect. ( e e l Q 5 p SINGLE FAMILY Temp. Power Pole &Appurtenances HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit 'e e e 4.5 v I hereby affirm that I am exempt from the Contractor's License additional Sign Branch Circuits Low'for the following reason (Section 7031.5, Business and Professions Code): 0 509788 ❑ I, as owner of the property, will do the work and the Misc. Conduits 8 Conductors structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ ► 7044, Business 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 PERMIT FEE (Sub-Total) (Sec. 3097, Civ. C.). PLAN CHECKING FEE Lender's Name PERMIT ISSUING FEE �a Lender's Address 1 certify that I have read this application and state that the TOTAL FEE above information is correct. I agree to comply with all County ordinances and State laws regulating Electrical wiring, and hereby a Ihorize resentatives of this County to enter upon r ///y� (/,L thea v -mens' ed prop ty for inspection pur os s. as/ J IrL 3 SEE REVERSE FOR EXPLANATORY LANGUAGE ig atu re a erm iuee Dat WORKERS'COMPENSATION DECLARATION 20 W19 w„a7 APPLICATION FOR ELECTRICAL PERMIT 5 I hereby affirm that I have a certificate of consent to self CFBOCC insure, or a certificate of Workers' Compensation Insuronce, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS or a certified copy thereof (Sec. 3800, Lob, C.) Policy N&JC_04000A32,4Q$pany�.[-r�yj],f�� FOR APPLICANT TO FILL IN JOB Certified copy is hereby furnished. New Residential Bldgs. 8 Pools EACH NO. FEE ADDRESS ARIA -nag JU Certified copy is filed with the county building inspec- 18 2-Family, Sq. Ft. $ _ $ LOCALITY Teri- City. CA tion department. Multi-family Sq. Ft. NEAREST NEARS CROSEST, Rngrrui Blue]- Date J /.z Residential Swimming Pools OWNER OR Applicant FIRM NAME Coi,inty of 11.0a, Angiolgi CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec_L—Light_Sw._ 'MAIL COMPENSATION INSURANCE i r ADDRES This section need not be completed If the work Involved b / First t . . ( P Y Total No.-14-- Additional CITY TelNo the permit is For one hundred dollars ($100)or less.) PLAN C I certify that in the performance of the work for which this 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 Additional Total No. CITY Tel No. Date Applicant Fixed Appliances Not Over 1 HP PERMIT NOTICE TO APPLICANT: If, after making this Certificate of APPLICATION 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 2316 W, Victory Blvd, with comply with such provisions or this permit shall be Top — FAU —W.H. — deemed revoked. Hood — Fan —Other— CITYIkirbAnit Tel, N LICENSED CONTRACTORS DECLARATION LICENSE Disp. — Room Air Cond. REG. NUMBER 364386 Closs,C—l0 OR I hereby affirm that I am licensed under provisions of Chapter 9 y (commencing with Section 7000)of Division 3 of the Business Power Apparatus 8 Large Appliances DISTRICT NO. PROCESSED BY d and Professions Code,and my license is in full force and effect. Size 8 Type HP, KW, KVA, or KVAR O License Number 364386 Lic. ClossC-.1^ Up to 1 Incl. FINAL - LU Over 1 to 10 11 DATE VALIDATION Contractor te '/ Z - t LL ❑ "J Over 10 to 50 Incl. FINAL Y I am exempt under Sec. Over 50 to 100 Inc. BY CC 6.8P.C. for this reason Over 100 Q Services, Swbd., MCC 8 Panelboords ► 0 Date: 0- 200 Amp. Under 600 V a Signature 201 - 1000 Amp. Under 600 V W ❑ Over 1000 Amp. or Over 600 V I-- Exemption for Reg. Mainz. Elect. SINGLE FAMILY Temp. Power Pole 8 Appurtenances HOME OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Sign with One Branch Circuit Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits Professions Code): I, as owner of the properly, will do the work and the Misc. Conduits 8 Conductors , structure is not intended or offered for sale(Section 7044, - Other (See Complete fee Schedule)— t. Business 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 PERMIT FEE (Sub-Total) (Sec. 3197, Civ. C). PLAN CHECKING FEE Lender's Name PERMIT ISSUING FEE - Lender's Address - I certify that I have read this application and state shot the TOTAL FEE above information is correct. I agree to comply with all County ordinances and State lows 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 / �• Ph Signature of Permittee Date