The URL can be used to link to this page

Home My Public Portal About4442 TEMPLE CITY BLVD_Electrical__ WORKERS COMPENSATION DECLARATION 7DPW 3/87 APPLICATION FOR ELECTRICAL PERMIT O I hereby affirm that 1 have o certificate of consent to self aaoea insure or a certificate of Workers Compensation Insurance COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS or a certified copy thereof (Sec 3800, Lab C ) PolicyNo Company FOR APPLICANT TO PILL IN JOB Certified copy is hereby furnished New Residential Bldgs 8 Pools EACH NO FEE ADDRESS a' — f Certified copy is filed �vuh the county budding m $spec 1 8 2 Family,Sq Ft LOCALITY tion department Multi family Sq Ft — NEAREST Residential Swimming Pools OWNS 57 01 Dote Applicant l OWNER FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS /// MAIL COMPENSATION INSURANCE Outlets Rec ".,77__Ught�Sw ADDRESS F First 20 (This section noel not un red dolga If the work Imrohred by Total No �� CITY Tel No NIR permit IF for one hundred dollen (f100)or kHs ) Additional 44- . 77 PLAN C CK if I certify that in ,he performance of the work for which this APPLICANT permit is issued, I shall not employ any person in any manner Lighting Fixtures First 20 ADDRESS so as to become subject to the Worker's Compensation Laws Additional Total No CITY Tel No Dote Applicant Fixed Appliances Not Over 1 HP PERMIT NOTICE TO APPLICANT If after making this Certificate of Ran Heater—D W — APPLICATION Exemption you should become subject to the Workers Range— Compensation provisions of the Labor Code you must forth Oven _ Dryer —W M _ ADDRESS with comply with such provisions or this permit shall be Top — FAU —W H — deemed revoked Hood — Fon —Other_ CITY Tel No J LICENSED CONTRACTORS DECLARATION LICENSE OR - I hereby affirm that I am licensed under provisions of Chapter 9 `Disp , Room Air Cond — REG NUMBER Class (commencing with Section 7000)of Division 3 of the Business Power Apparatus 6 Large Appliances_ DISTRICT NO PWSSED BY d and Professions Code,and my license is in full force and effect if Size 8 Type HP, KW, KVA, or KVAR 0 License Number L¢ Class Up to 1 Incl FINAL Over 1 to 10 Ind DATE p I A Q Contractor Date r� VALIDATION 0 ❑ Over 10 to 10 Incl FINAL C~.3 I am exempt under Sec Over 50 to 100 Inc BY W B BP C for this reoson Over 100 LU Services Swbd MCC B Ponelboards - U) Dote ? 0-200 Amp Under 600 V Signature 201 1000 Amp Under 600V QExemption for Reg Moms Elect Over 1000 Amp or Over 600 V SINGLE FAMILY Temp Power Pole 8 Appurtenances HOME OWNER-BUILDER DECLARATION - ` Sign with One Branch Circuit - - c hereby affirm that I g r exempt from the Contractor s License FT.i .r Law for the following reason (Section 7031 Sr loess and Additional Sign Branch Circuits Professions Code) ' "SIJ Yom, I as owner a prth operty, wdl CIO th ark and the Misc Conduits 8 Conductors j I - structure is not intended or offered for sale Section 7044, Other (See Complete Fee Schedule}_ , Buarnew and Professions Code) CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency forpt the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) J .IJIu (Sec 3097 Gv C ) PLAN CHECKING FEE Lenders Name /� Q[Ifl'I-fl[Uri liltll/yi PERMIT ISSUING FEE 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 _ ordmonces and State laws regulating Electrical wiring, and r hereby authorize representatives of this County to enter upon the above mentioned property far insp on purposes s/L \ SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date ms