HomeMy Public PortalAbout6112 MUSCATEL AVE_Electrical__ WORKERS'COMPENSATION haveDECLARATnse� r`'�7� ,APFLIC;I�TION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certif+cate of tcon ,� self CE-806G
insure, or a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES ,! BUILDING AND SAFETY
or a certif' d copy thereof(Sec. 3800, Lab. C.) Tt
Policy ryb} .!i 1ZAL gompany FOR APPLICANT TO FILL IN JOB
Certified copy is hereby furnished. New Residential Bldgs. &Pools EACH NO. FEE ADDRESS 6112 Muscatel
nY. q• Ft.
1 &2-Family, s $ = a LOCALITY Temple City
}tel Certified copy is filed with the county building inspec- A
tion department. ,//� / (/ Multi-family Sq. Ft. CROSS NEAREST
T.
^' _4; A licar�#� "� ��' ! Residential Swimming Pools OWNER OR
Date pp FIRM NAME Belia Horvath
CERTIFICATE OF EXEM ON FROM WORKERS' Outlets: Rec 8 Light 6 sw. 6 MAIL 6112 Muscatel
COMPENSATION INSURANCE ADDRESS
This section need not be com letod if the work involvod b First 20
�d
( p 1r Total No. 20 Additional CITY Temple Cit Tel. No.
the permit Is for one hundred dollars($100)or less.) PLAN CHECK
I certify that in the performance of the work for which this APPLICANT N/A
permit is issued, I shall not employ any person in any mannerJy
so as to become subject to the Workers'Compensation Laws. Lighting Fixtures6 First 20 ADDRESS N/A
Total No. Additional CITY NIA Tel. No. NIA
Date Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, after making this Certificate of APPLICANTTJ
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 9067 E. Las Tunas D
r% QA41
with comply with such provisions or this permit shall be Top — FAU —W.H. —
deemed revoked. Hood _ Fan —Other_ CITYTemple City Tel. No.
LICENSED CONTRACTORS DECLARATION LICENSE OR
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. _ Room Air Cond. REG.NUMBER 451865 Class. B
(commencing with section 7000)of Division 3 of the Business DISTRICT NO. PRO SED BY
and Professions Code,and my license is in full force and effect. Power Apparatus&Large Appliances �- �/ v IL
451865 Size&Type HP, KW, KVA, or KVAR �7/D Q O
License Number Lic. Class B Up to 1 Incl. FINAL
Builders Inc• DATE at
ContractorD & W Associate Date May 1, ,1.984 Over 1 to 10 Incl. �,� VALIDATION d
❑ Over 10 to 50 Inc]. FINAL
I am exempt under Sec. Over 50 to 100 Inc. BY Im
Over 100
B.BP.C. for this reason
Date: Services, Swbd., MCC&Panelboards
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.
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 Additional Sign Branch Circuits
Law for the following reason (Section 7031.5, Business and
Professions Code):
❑ I, as owner of the property, will do the work and the Misc. Conduits&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) A
(Sec. 3097, Civ. C.).
PLAN CHECKING FEE
Lender's Name PERMIT ISSUING FEE o 11
Lender's Address
I certify that I have read this application and state that the TOTAL FEE oar
above information is correct. I agree to comply with all County
ordinances and State laws regulating Electrical wiring, and
hereby authorize re resentativ.sof this County to enter upon
the above-mentio a propert or inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date