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HomeMy Public PortalAbout6314 SULTANA AVE_Electrical__ WORKER'S COMPENSATION DECLARATION 20.0019 DPW(12.91) APPLICATION FOR ELECTRICAL PERMIT � • I hereby�affirm'that I have a certificate of consent to self insure. 7gA663 or 1 certificate of Worker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS BUILDING AND SAFETY DIV. copy thereof(Sec.3800 Lab.C.) paD AS/policy No.N0. 6— ,J Company S¢L�' f U�� FOR APPLICANT TO FILL IN SOB P�� i ADDRESS C7 El Certified co is hereby furnished. NO. EACH FEE PY Y New Residential Bldgs.&POOIS _ $ $ LOCALITY ��� G� Certified copy is filed with the county building inspection 1&2-Family,Sq.Ft. _ NEAREST department. Multi-family Sq.Ft. CROSS ST. Date��sig� pplicant G d��✓�%' G©A/S� Residential Swimming Pools ASSESSOR ,, MAP BOOK 3��. PAGE 019 PARCEL 0 CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec._—V Light--d5(_Sw._C2FFINA IRM ME COMPENSATION INSURANCE First 20 MAIL (This section need.not be completed if the work Involved by the Total No. _ Additional ADDRESS a ! [/ N permit is for one hundred dollars($700)or less.) / f / I certify that in the performance of the work for which this permit 1 �.� Job CITY j G Tel.No. is issued, I shall not employ any person in any manner so as to PLAN CHECK If become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 APPLICANT Total No. Additional dr V ADDRESS Date Applicant RESIDENTIAL APPLIANCES NOT OVER 3 HP. NOTICE TO APPLICANT: If, after making this Certificate Of CITY Tel.No. Exemption,you should become subject to the Workers'Compensation OTHER APPLIANCES NOT OVER 3 HP. provisions of the Labor Code,you must forthwith comply with such PEFLCANT s✓Q jl/(yam ee3J�/ provisions or this permit shall be deemed revoked. Power Apparatus&Large Appliances LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS s ,� I hereby affirm that I am licensed under provisions of Chapter 9 Over 3 to 10 Incl. (commencing with Section 7000) of Division 3 of the Business and CITY Tel.No. Professions Code,and my license is in full force and effect. Over 10 to 50 Incl. LICENSE OR >_ Over 50 to 100 Incl. REG.NUMBER d 6 Class. IL Over 100 DISTRICT NO. P C ED BY 0 License Number_3421 1L' '7 Lic.Class 0 Services,Swbd.,MCC&Panelboardsit Contractor G D Aiv[5'R C,aahaate 0-399 Amp.Under 600 V DAA O ❑ I am exempt under Sec. 400-1000 Amp.Under 600 V -3 l 17 � VALIDATION w Over 1000 Amp.or Over 600 V FINAL a. B.&P.C.for this reason BRANCH CIRCUIT FEES BY W Date: 15A,or 20A,120V,Lighting or Recept. `��� Z 1 To 10 Branch Circuits Signature i 1 To 40 Branch Circuits F-141 Or More Branch Circuits Exemption for Reg.Maint.Elect. 15A,20A,208V To 277V Lighting Br.Circuits SINGLE FAMILY Temp.Power Pole&Appurtenances HOME OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits �ti•_�-� :+= ='- Code): ❑ Misc.Conduits&Conductors r 'I,as owner of the property,will do the work and the structure s r is not intended or offered for sale(Section 7044, Business Other(See Complete Fee Schedule) ® �;iH_' 60_ 61:3 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(Sec. 3097, PERMIT FEE (Sub-Total) Civ.C.) _ PLAN CHECKING FEE Lender's Name / PERMIT ISSUING FEE Lender's Address /_O I certify that I have read this application and under penalty of purjury state TOTAL FEE (� that the above information is correct. I agree to comply with all County ordinances and State laws 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 l!' :? OLR SIGNATURE 0;PENMrrn2E DATE r 4+ WORKER'S COMPENSATION DECLARATION 2"019 DPW 9/88 6=,1PPUCATE®IICI FOR 2n ECTMCAL PERMT aff• �� IICI I�L� U'n ��y� I hryrpby�,, njl117+ti,tif I gave a certificate of consent to self insure, or a certificate of Worker's Compensation Insurance,or a certified COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS BUILDING AND SAFETY DIV. fopy thereof(Sec.3800 Lab.C.) W , No 4 7 9 7 0 2-0 5company Fremont FOR APPLICANT TO FILL IN JOB ADDRESS 6 314 Sultana Ave. E] Certifiedcopy Is hereby furnished. New Residential Bldgs.&Pools EACH NO.. FEE El LOCALITY — Temple Cit Certified copy is filed w 1&2-Family,Sq.Ft. $ $ with the county building inspection _ NEAREST department. Multi-family Sq.Ft. CROSS ST. Longden Date Applicant AAA COnd Ai r Residential Swimming Pools ASSESSOR PARCEL MAP BOOK PAGE CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER OR Outlets:Rec._Light Sw. FIRM NAME Wong COMPENSATION INSURANCE g First 20 MAIL (This section need not be completed If the work Involved by the Total No. Additional ADDRESS 6314 Sultana Ave. permit Is for one hundred dollars($100)or less.) I certify that in the performance of the work for which this permit CITY Temple City TBl."0.2 85-0322 Is issued, I shall. not employ any person in any manner so as to PLAN CHECK become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 APPLICANT Total No. Additional ADDRESS Date Applicant 15 OR 20A,120V BRANCH CIRCUITS NOTICE'TO APPLICANT: If, after making this Certificate of CITY Tel.No. Exemption,you should become subject to the Workers'Compensation 1 T010 INCLUSIVE EACH provisions of the Labor Code,you must forthwith comply with such 11 TO 40 INCLUSIVE EACH PERL11CANT AAA Conditioned Air provlsions or this permit shall be deemed revoked. 41 OR MORE BRANCH CIRCUITS EACH y. LICENSED CONTRACTORS DECLARATION ADDRESS 0. I hereby affirm that I am licensed under provisions of Chapter 9 15 OR 20A,208V TO 277V LIGHTING EACH10160 Val ley RludO (commencing with Section 7000)of Division 3 of the Business and CITY El Monte Tel'"0-579-1800 U Professions Code,and my license is in full force and effect. RESIDENTIAL APPLIANCES UP TO 3HP LICENSE OR Power Apparatus&Large Appliances REG.NUMBER 293529 C'--C20/1 0 License Number 2 9 3 512 9 Lic.ClassC 2 0 ] 0 . Size&Type HP,KW,KVA,or KVAR �j� DISTRICT NO. PRC D BY 1-- 1 —3—h �Jp°to 3 Incl. Q b s V VU.1Over 3 to 10 Incl. FINAL a Contractor .AAA Cond Air Data 11/30/93 DATE CO ❑ Over 10 to 50 Incl. "�� I am exempt under Sec. Over 50 to 100 Incl. f ! VALIDATION FINAL BAP.C.for this reason Over 100 BY Services,Swbd.,MCC&Panelboards Date: 0-200 Amp.Under 600 V Signature 201-1000 Amp.Under 600 V ❑ Exemption for Reg.Ma(nt.Elect. Over 1000 Amp.or Over 600 V SINGLE FAMILY Temp.Power Pole&Appurtenances + HOME OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit I-t=� °a for the following reason(Section 7031.5, Business and Professions Additional Sign Branch Circuits 333-3,f °sc Code): � _ ❑ I,as owner of the property,will do the work and the structure Misc.Conduits&Conductors Is not intended or offered for sale(Section 7044, Business Other(See Complete Fee Schedule) U T AL 45 . 15 and Professions Code). { r- • I -• .HEL-{ 't•1 a til 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, PERMIT FEE (Sub-Total) Civ.C.) PLAN CHECKING FEE 1010010-0-11 11/3 3.01 x`753 Lender's Name y; PERMIT ISSUING FEE ;i7 ti13 :ki` Lender's Address I certify that I have read this application and state that the above TOTAL FEE information is correct. I agree to comply with all County ordinances and State laws regulating Electrical wiring, and hereby authorize representatives Of Nils Countylo e r upon the above-mentioned property for ins acM®rts SEE REVERSE FOR EXPLANATORY LANGUAGE vi 11-30-93 SIGNATURE OF APPLICANT OR AGENT DATE