HomeMy Public PortalAbout4847 TEMPLE CITY BLVD_Electrical__ IWORKER sCOMPENSATION DECLARATION 720-0019 6AMDPW9,� APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self insure 761Be3
or a certificate of Worker a Compensation Insurance or a certified COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV
copy ther&ol(Sea 3900 Lob C I - - -
policy No Carnpany, FOR APPLICANT TO RLL IN ADORE
❑ Certified copy or hereby furnished New Residential Skiffs 8 Poole -EACH NO FEE
162 Family SM Ft $ — $
dLOCALRY
❑ e +
Mletl copy le filed with the county inspection
P I Multl(amity Sq Ft — _ NEAREST
CROSS Tg
Data Applkem Residential Swimming Pools ASSESSOR
_ MAP 9001( PAGE PMCF1
CERTIFICATE OF EXEMPTION FROM WOI TERS Outlets Rec _UQM_Sw _ OWNER OR
COMPENSATION INSURANCE FIRMNAME
(This potion need not be completed N the work Involved by the Total No dna al t _� ss
permttla lar one hundred dollars(5100)or leu) - ` I
1, elk
I certify that In the performance of the work for which this permit I CRV - Tel
i
is issued I shallnot employ any person in manner so ea to PLAN ClIEM
to
_
become subject to the Workers Compensation Lawn I- Lighting Fixtures First 20 CANTANi
Tobi No Atldnic"
ADDRESS
Dere Applicant of 15 OR 20A 120V BRANCH CIRCUITS
NOTICE TO APPLICANT a eller o the this certificate omesa of 1 TO 10 INCLUSIVE EACH CT' TSI No
plemptwn you should become subject to the Workers Compensation such
provisions of the permit
Code you must forthwith comply with each 11 T040 INCLUSIVE EACH - APPLPERLICANT T
APPI CM T
prowaiona or this IC perms shell be deemed revoked 11 OR kIDRE BRANCH GRCUf7$EACH
LICENSED CONTRACTORS DECLARATION - - - - ADDRESS - }
I hereby affirm that I em licensed under provisions of Chapter 9 15 OR 20A 20SV TO 277V LIGHTING EACH a
(commencing with Section 7000) of Division 3 of the Business and _ _ _ _ CITY IN No 8Professions Code and my license is In lull force and effect RESIDENTIAL APPLIANCES UP TO SHP LICENSE OR Glue IM
Power Apparatus A Large Appliances _ _ _ REO NUMBER _ O
License Number W Class Sim E Type HP KW KVA or KVAR MTRICT NO (J BY F
Up to 3 Ind
Over 3 to 10 Incl FINALContrd
edw Date - Over 10 to 60 IMI onTE
I am exempt under Sec Over 60 to 100 Ind �O -Z C / VALIDATION F Z
Over 100 _ FINAL
S BP C for this reason By
Services C E Penelboerde 10 _
- Date 0 P r 900 V 1:5;141
Signature 201 1000 Amp Under NOV
❑ Exemption for Reg Meant Elea - Over 11X10 Amp or Over 800 V
SINGLE FAMILY Temp Power Pole 9 Appurtanences
HOME OWNER BUILOER DECLARATION Sign with One Branch
I hereby affirm that 1 am exempt from the Contractor a License Law GmuR
for the following reason(Section 7031 5 Business and Professions Addllronal Sign Branch Circuits - - .:�•j7 c'r,.
Code)
lye -Mist Conduits B Conductors -' = lTt�� .•
tet' I,ea owner of the property will da the work and the structure
is not intended or offered for sale(Section 7044 Business Other(See Complete Fee Schedule)_ ► 1{)TSL 59 n 5= 1
and Professions Code) ' J
CONSTRUCTION LENDING AGENCY (-
I hereby affirm that there is a construction lending agency for the I_I�iTIiILC .lU
.5 performance of the worn for which this permit is issued (Sec 3097 PERMIT FEE - _ - _(Sub Total
CIv C)
PLAN CHECKING FEE
Lender a Name—00-p r/M �.f�=411-
PERMIT ISSUING FEE _ a j 1 A{iI!
i(l:{�
Lender a Address
I certify that 1 have res this application end state that I ebo e TOTAL FEE
information is correct I agree to comply bh all County oInances
and State sawn regulating Electrical wiring and hereby uthorize
rep sentetives of IN County to enter upon the above mer)tloned
p rty for map tion purposes / SEE REVERSE FOR EXPLANATORY LANGUAGE
PAPP AD NT D E' ,