HomeMy Public PortalAbout4420 TEMPLE CITY BLVD_Electrical__ • WORKERS COMPENSATION DECLARATION aea 10,81 APPLICATION FOR ELECTRICAL PERMIT {�
I hereby affirm that I have a certificate of consent m self InsuCE eO re �eO �J
or a csrlif"te of Workem Compensation Insurance or a caroled COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy ttemof(Seo 3800 Lab C) 1
Policy No Company FOR APPLICANT TO FILL W JOB
❑ Certlled copy B hereby furnishedblew Residential Brigs d Pods • EACH NO , FEE ADDRESS L
❑ Garbled copy is iJed with the county building inspection1 d 2-Family, S41 Ft $ — $ LOCALITY e
department Mufu-family, So Ft — NEAREST
CROSS ST
Date
Applicant g Residential Swimming Pools OWNER OR
^ FIRM NAM -
CERTIFICATE OF EXEMPTION FROM WORKERS Outlets Rec—1 Light _ Sw MAL
COMPENSATION INSURANCE First 20 ADDRESS. '
^ (This section need trot be competed If the work Involved by the ' CITY i Tel No
permit Is for one hundred dollars ($100)or lase) Total No Additional7 �/-
I certify that in the Performance of the work or which the pernnt PLAN CHECK
e issued I shall not employ ar1Y person i manner so as to APPLICANT
become subject to the Workers Compe i Lighting Fixtures First 20 ADDRESS
Total No Addifq�t 1
Data- ApplicantCITY Tel No
NOTICE TO APPIJCANT d after this Certificated Fixed Appliances Not Over 1 HP PERMIT
Ezemptgn you should become subject tot ora Compensation
Range_ Heater_ DW APPLICANT
prowarens of the Labor Code you must forthwith comply With such Oven _ Dryer _ W M _ ADDRESS
provisions or this permit shall be deemed revoked _ Top _ FAU _ WH _ Cm• Tel No
LICENSED CONTRACTORS DECLARATION Hood _ Fan _ Other_
I hereby affirm that I am licensed under prowsgre of Chapter a DIBP Roan Air Cord UCENSE on
(commencing with Section 7000)of Diss" 3 of the Buramoss —
and REO NUMBER Gass.
Professions Code ant my license a in full tome and effect {ower Apparatus d Large Appuanoea DISTRICT NO �f By
T
Sae d Type HP KW KVA or KVAR r 0v
License Number Lc Class UP to 1 Inc] - FINAL
Over Ito 10Inc1 DATE DJC/ G Q
Contractor Date Over 10 m 50 Ind
ElFlNA FF
am exempt under Sec •Over 50 to 100 Inc BY U
SAP for the reason - Over 100
' Services Swbd MCC d Penelboarla _
Date - O-200 Amp Under 600 V
Sgnature 201 - 1000 Aran Under 600 V
❑ - Over 1000 Amp or Over 600 V
Exemption for Reg Maint Elect
r SINGLE FAMILY Temp Power Pole d Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Grcun
I hereby affirm that I am exempt from the Contractors Llcanse'Law
for the following reason(Section 7031 5 Business and Profem
sate Additional Sign Branch Coalite _
Code) yl,
I as owner of the property will do the work and the structure A4sc Conducts d Condgtors
is rot intended or offered for sale (Section 7044 Busiress Other(Sea Complete Fee Schedule) _ ► Y109�'
and Professions Gods) • - y e
CONSTRUCTION LENDING AGENCY - #Q a B
11lereo
by affirm that there is a calructlendingnlending agarloy for the D n Yes Cpl
' Performance of the work for wfoch this perms m issued(Sec 3087 PERMIT FEE (Sub-Total)
Cry C)
PLAN CHECKING FEE
Lenders Name -
' PERMIT ISSUING FEE _
Lenders Address
I certify that I heme read this application and stele that the above TOTAL FEE
information a correct I agree to comply Wth all Courtly ordinances `
and State leas regulating E I mring and hereby auther¢e
represents0,4 of this to enter upon the above-mentgnerd ,
pr �� SEE REVERSE FOR EXPLANATORY LANGUAGE - -
n
'64ristufff of
rttee Date - '