HomeMy Public PortalAbout4510 TEMPLE CITY BLVD_Electrical__ WORKERS COMPENSATION DECLARATION - 76A663 '10/81 {►
1 hereby affirm that I have a certificate of consent to self CE 806r, APPLICATION FOR ELECTRICAL PERMIT
insure or o certificate of Workers Compensation Insurance COUNTY OF LOS ANGELES "BUILDING AND SAFETY
Tor a certled copy thereof (Sec 3600 Lab C )
❑ .!� Company FOR APPLICANT 70 RLL IN I JOB
Certified copy is hereby furnish New Residential Bldgs 8 Pools EACH NO FEE ADDRESS
Certified copy is filed with the county building nspec- 18 2-Family, Sq Ft $ M— NEARIEST
OCALITY
hon department Multi family Sq Ft Residential Swimming Pools ROSSSr
Dote Applicant WNER OR
RM NAMECERTIFICATE OF EXEMPTION FROM WORKERS' Outlets ReclsLLight 1s�$w 1�COMPENSATION INSURANCE ESS Off'AIL
(This section need not be completed If the work Involved by First 20ITh Tel No .2 3
the permit Is for one hundred dollars ($100)or less ) Total No�� Additional
I certify that in the performance of the work far which this ,�IUN�
permit is issued I shall not employ any person in any manner
so os to become subject to the Workers Compensation Laws Lighting Fixtures First 20 ADDRESS .0
Total No Additional r
Dote Applicant �Z CITY Tel No
Fixed Appliances Not Over 1 HP
1:�ficgs�ii
NOTICE TO APPLICANT 'If, after making this Certificate of PE IT _
Exemption, you should become subject to the Worker Range_ Heoler_DW — APPIL
Compensation provisions of the Labor Code, you must forth- Oven 1 Dryer W M — ADDRESS
with comply with such provisions or this permit shall be Top _ FAU .L W H
deemed revoked CITY Tel No -
LICENSED CONTRACTORS DECLARATION Hood L Fan _Other_
G
Disp -Room Air Cond NClass
I hereby affum that I am licensed under provisions of Chapter 9 REG
NEG NUMBER
(commencing with Section 7000) of Division 3 of the Business Power Apparatus 8 Large Appliances _ DISTRICT NO ED BV y
and Professions Code and my license is in full force and effect d
Size 8 Type HP KW KVA or KVAR xi O
License Number 7-360637 La ClassUp to 1 Incl— - FINAL - V
/
Contractor pate —2� Over 1 to 10 Incl GATE �('' VALIDATION FQ
a _ Over 10 to 50 Incl FINAL - y
I am exempt under Sec Over 50 to 100 Inc BY G
B 8P C for this reason - Over 100 2
Dat Services S , MCC Panelboards
A , -
0 -200 Amp Under 600 V
Signature 2 7fi--M Amp Under 600 V
❑
Exemption for Rep MOver 1000 Amp or Over 600 V
mnt Elect
SINGLE FAMILY Temp Power Pole& Appurtenonces
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby affum that I am exempt from the Contractor s License Additional Sign Branch Circuits
Law for the following reason (Section 7031 5 Business and
Professions Code) 9 3 51 A
s _
as owner of the property will do the work and the
Misc Condwts 8 Conductors
structure is not intended or offered for sole (Section Other (See Complete Fee Schedule)_ ► � • • • s • 2
7044 Business and Professions Code)
CONSTRUCTION LENDING AGENCY r _P • ' 8 A 7 5
I hereby off irm that there is a construction lending agency for 8 7 Jc
the performance of the work for which this permit is issued PERMIT FEE (Sub Total) .- r
(Sec 3097, Civ c ) N CHECKING FEE 0 1.25-83
t
PLA -• - _
Lender s Name
PERMIT ISSUING FEE
Lenders Address
I certify that I have read this application and state that the TOTAL FEE
above information is correct I agree to comply with all County
ordinances and State jaws regulating Electrical wiring and -
hereby authorize representatives of this County to enter upon -
the ve mentioned arty for inspection purposes
)_L s��� SEE REVERSE FOR EXPLANATORY LANGUAGE
M
gnoture of Perm.".pG pate