HomeMy Public PortalAbout4829 TEMPLE CITY BLVD_Electrical__ � WCAKEBS COMPENSATION DECLARATION 76Aee3 10,e1
OE to60 APPLICATION FOR ELECTRICAL PERMIT {�
fi hereby aHum ve.that I haa oertdisam of consent to self Insure u
or a ebdifcate of Porkers Compensation Insurance or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy �O Se3800b C)
� p
aryforxFutJD-F&9
FOR APPLICANT TO F61 IN JOB
® Certified copy Is hereby furnished New Residential Bldgs 8 Pools EACH NO FEE ADDRESS
Mud
(u^ Certified copy a filed with the county building inspection 1 8 2-Famtly So Ft r R__,__ $ — $ LOCALITY
department Mulb-family Sol Ft NEAREST r.
Date. -M ApplicantResidential Svnmmlrp Pools O EER OSS OR
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS Outlets Roo,—7—
Light � Sw MAA ��
COMPENSATION INSURANCE Q ADDRESS
_ CITY Tel No
(This section need riot be completed H the work Involved 20
vetl by the Toll Additional
permit Is for one hundred dollars($100) air bee) - —
I certify that In the performance of the work for which this permit PLAfI CHECK
* Issued I shell not employ arty person in any meaner so as to • _ i
become subled to the Workers Compensation Laws Lighting Fixtures First 20 ADDRESS 2
�j Additional
Date Applicant
Total No _f - CITY CIA
Tel No
NOTICE TO APPLICANT If after making this Certificate of Fixed Appliances Not Over 1 HP PERMIT
Exemption you should become subject to the Workers Compersaton Range— Heater_ DW _ API�.tI�NT 0-4
pnanslons of the Labor Cade you must forthwith comply with such Oven _ Dryer _ W M _ ADDRESS
provisions or this permit shall be deemed revoked Top _ FAU _ WH
LICENSED CONTRACTORS DECLARATION Hood — Fan Other_
CITY Tel No
I hereby affirm that I am licensed under provisoes of Chapter 9 asp _ Rope Air Cord LICENSE OR C�
(commencing with Section 7000)of DNson 3 of the Business and REG NUMBER
Professions Code and my license a in full force and effectDISTRICT NO PROCESSE BV
Raver Apparatus 8 Large Appliances
p�� Size A Type HP KW KVA or KVAR �D
il 10.
License Number 6 0 2I���d 7 Lic Class Up to 1 Incl FINAL L� `"
a_2� Over Ito 101ncl DATE S 7 �!/ `Z VALIDATION C
Contractor7� �• 4mere !j n Over 10 to SO tact
❑ I em exempt under Sac Over 50 to 100 Inc: yam, A(LT.i ty��
BBPC for this reason Over 100 VVV j 7 40.99
Services Swbd MCC 8 Pane boartg t e ► 1 I�.�y� �z
Date - 0-200 Amp Under 800 V i O I G I�
Signature 201 - 1000 Amp Under 800 V TOTAL 40 . 90
❑ Exemption for Reg Mani Elect Over 1000 Amp or Over 800 V �x.yr.���((yy// [ 90
- 41Y1 r1 40.90
SINGLE FAMILY Temp Power Pole 8 Appurtenances CWINE .00
HOME OWNER BUILDER DECLARATION Sign with One Branch Clrcud
I hereby affirm that I am exempt from the Contractors License Law
for the following reason(Section 7031 5 Bus mese and Rofesslos Additional Sign Branch Circuits -
Code) 0000-0001 9/28/90
❑ 1 as owner of the property vnll do the work and the structure Misc Conduits 8 Conductors -
is not intended or offered for sale (Section 7044 Busmi Other (See Complete Fe --mxi�e�ae Schedule) _ ipJ+O.I 1 AM 9.23
and Pmfeseons Code)
pol-
CONSTRUCTION LENDING AGENCY
I hereby affirm that there Is a construction lending agency for the
perlormeroe of the work for which this permit a*sued(Sec 3087 PERMIT FEE (Sub-Total)
CN C)
PLAN CHECKING FEE
Lenders Name
PERMIT ISSUING FEE -.
Lender s Address
I certify that I have mad this applicator, and sate that the above TOTAL FEE
information Is correct I agree to comply vnth all County ordinances
` and State laws regulating Electrical wining and hereby authorize '
repnesentatnes of Ms County to enter upon the above-mentioned
property for Inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature rm ee r Date