HomeMy Public PortalAbout4500-4502-4504-4506 TEMPLE CITY BLVD_Electrical__ {tORKERS'COMPENSATIONDECLARATION 76.663 ,a,B, ' APPLICATION FOR ELECTRICAL PERMIT
hbreby affirm that I have a certificate of consent to self
insure,. r a ceNiricate of Workers Compensation Insurance �w� COUNTY OF LOS ANGELES S_�BUILDINGG AND SAFETY
of a certified copy thereof/Sec 3800, Lab C ) y• t
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Policy No -W—P o Any,"CAJFAC W�r[/✓Q` FOR APPLICANT TO FILL IN JOB
Certified copy �s hereby furnished New Residential Bldgs 8 Pools EACH NO FEF ADDRESS
❑ Certified copy n filed with the county budding mspec- 1 8 2 Family Sq Ft T — S LOCALITY e%
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hon deportment Multi family$q FI '7g Pools CRASS NEARESSTT
ppO /Q
Date i/per ghcan Residential Sw.mmin�f -����"�� R
FIRM
CERTIFICATE OF EXEMPTION FROM WORKERS Outlets Rec_Light_Sw_ 'M'R �O
COMPENSATION INSURANCE Fant 20 ADDRESS p�
(This section need not be completed if the work Inwlved by Total No Arst20 l CITY — Tel No 93 p
the permit IF for one hundred dollars ($100)or less ) PIAN CHECK
certify that in the performance of the work for which this APPLICANT N 1G•r .cmc
permit is issued I shall not employ any person in any manner s
so as to become subject to the Workers Compensation Lows Lighting Fixtures Fiat 20 ADDRESS
Total No Additional
CITU ��N Tel No .;fb,?
Date Applicant Feed Appliances Not Over I HP PERMIT
NOTICE TO APPLICANT If, after making this Certificate of ERMIT -
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 ezr4l'6551
with comply with such provisions or this permit shall be Top — FAU —W H —
deemed revoked Hood _ Fan _Other_ CITY i�J Tel No
LICENSED CONTRACTORS DECLARATION LICENSE OR
1 herebyaffirm that I am licensed under p Disp _ Room Air Canal Class
provisions of Chapter 9 REG NUMBER -/go—
(commencing
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(commencing with Section 7000) of Division 3 of the Business DISTRICT D BY
and Professions Code and my license is in full force and effect Power Apparatus 8 Large Appliances antes yr
�3_293� e/O Size 8 Type HP, KW KVA or KVAR 6
License Number Uc Classs� Up to I Incl FINAL / V
otitrdct-Sr'N�` "'� Date //����s Over 1 to 10 Ind DA�� �C-�J V UDATION •• 0
❑ Over 10 to 50 Incl FI
I am exempt under Sec Over 50 to 100 Inc
916
B 8P C for this reason Over 100 Z
Date Services Swbd MCC 8 Ponelboards
0 200 Amp Under 600 V
Signature 201 1000 Amp Under 600 V
❑ - Over 1000 Amp or Over 600 V -
Exemption for Reg Mainz Elect
SINGLE FAMILY Temp Power Pole 8 Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Grant �2 4 3131-1
q . . . . ..2
I hereby affirm that I am exempt sn ( from the Contractor s License Additional Sign Branch Circuits
Law for the following reason (Section 7031 5 Business and _ g I •r1 5 7.7 8
Professions Cade) _ e • 1 5 7.7 8'5'
❑ I as owner of the property will do the work and the M�sc Conduits 8 Conductors "' is
not intended or offered for sale (Section Other (See Complete Fee Schedule)_ ► 07, 11 -,85
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 the permit is issued PERMIT FEE (Sub Total) _
(Sec 3097 Ctv C )
rj /C/`��� �s�u� A�� PLAN CHECKING FEE _
Lenders Name 3_ '1
i��7 PERMIT ISSUING FEE _ {�
Landers Addre%s� .�iD�6 S/. ��l•Pf .!.✓ C.-.if '
I certify that I have read this application and state that the TOTAL FEE _ t
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
t ve-mentioned property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
ignoture of Permittee Dote