HomeMy Public PortalAbout9034 PENTLAND ST_Electrical__ 'WORKERS COMPENSATION DECLARATION 76A663
CE806G 12901 APPLICATION FOR ELECTRICAL PERMIT
4 + 06Ll
1 hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES / BUILDING AND SAFETY
insure or a certificate of Workers Compensation Insurance or T f C - ,
a certified copy thereof(Sec 3800 Lab 5) n _
�0 G y t G — FOR APPLICANT TO FILL IN JOB n
Policy NQ /�� Com'Pany /_' ��'-""'GGG'wt+' ADDRESS)034 Pentland Street
!❑ New Residential Bldgs &Pools EACH NO FEE
Certified copy Is hereby furnished 1 &2 Family.Sq Ft $ $ LOCALITY Temple City
Certified copy Is filed with th unty budding spection Multi family Sq Ft CROSS ST .rrA iY�
department Residential Swimming Pools , OWNER OR 'rte`•
FIRM NAME ming Chou
Dai9-21 -34 Applicant Outlets Ree_Light_Sw _ MDDR
First,20 ESS 9034' Pentland Street
CERTIBICATE OP EXEMPTION FROM WORKERS Total No Additional CITU ' Temple Cut y Tel N0309-9072
COMPENSATION INSURANCE
PLAN CHECK d
(This section need not be completed if the work mvotved Lighting Fixtures Additional First 20 i APPLICANT U
Total No
,by the permit is for One hundred dollars ($100) or less) ADDRESS
I certify that in the performance of the work for wti¢h this ^ CITY Tel No w C)
permit u is+ued, 1 shell not employ an Fixed Appliances Not Over 1 HP . I—
D D Y y person in any manner PERMIT W
so as to become subject to the Workers' CompensattonrLasysRange_ Heater_D W APPLICANT ,fid I70 r El e c t r l c CO . d
Oven — Dryer_WM 3 50 1 350 ADDRESS315 S . San Gabriel B1 z
Date Applicant Top _ FAU _W H
Hood _ Fan _Other_ CITY San Gabriel TelNo287_0477
NOTICE TO APPLICANT If after making this Certificate of Dista _ Room Air Cond_ LICENSE OR '
Exemption you should become subject to the'Workers REG NUMBER 421797 Clesa C10
Compensation provisions of the Labor Code, you must forth Power Apparatus& Large Appliances DISTRICT NO PROC SED BV
with comply with such provisions or this permit shall be Size&Type HP KW KVA or KVA /+
deemed revoked Cl
Up to 1 Incl
Over 1 to 10 Incl FINAL
+
LICENSED CONTRACTORS DECLARATION Over 10 to 50 Incl DATE O VALIDATION
F
I hereby affirm that 1 am licensed under provisions of Chapter Over 50 to 100 Inc INALBV
9 (commencing with Section 7000) of Division 3 of the Bust Over 100 / s
ness and Professions Code and my license 6 in full force and 6 ,
effect Services 15 0 1 15 0
0 200 Amp Under 600 V
License Numbe, 'a 79 7 Class C 1 201 1000 Amp Under 600 V
Contractor}_,V'c L; to 9-.21 -84 Ovar 1000 Amp or Over 600 V i
77
HOM OWNER BUILDER DECLARATION Temp Power Pole& Appurtenances 2i•le 2 $5 O
'
1 hereby that 1 am exempt from,the Contractors Sign with One Branch Circuit r a 1e r, 5 Q
License Lewwfor for the following reason (Section 7031 5 Bust � Additional Sign Branch Circuits
ness and Professions Code)
09,26 -84
MisI as owner of the property will do the work and the Other
Conduits& Conductors
Other (See Complete Fee Schedule)—
structure is not intended or offered for sale (Section7044, Business and Professions Code) f
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 (Sec 3097 Civ C ) PERMIT FEE (Sub Total) 1 850 ,
Lender's Name PLAN CHECKING FEE (One Fourth Permit Feel s
Lenders Address PERMIT ISSUING FEE 1050 '
1 certify that I have read this application and state that the TOTAL FEE 2850
above information Is correct I agree to comply with all County ' 1
ordinances and State laws regulating Electrical wiring and
hereby ay^ onze representatives of this County to enter upon '
'he
2�r inspection purposes SEE REVERSE COR EXPLANATORY LANGUAGEX9-21 -84
S ne ure of Permittee Date
i