HomeMy Public PortalAbout5017 TEMPLE CITY BLVD_Electrical__ —rm that i'have a certificate
DECLARATION 76AM DPW(12 9„ APPLICATION FOR ELECTRICAL PERMIT
I Ikeraby affirm that I have a cernOcate of consent to self meure 78Aea3
or a certificate of Worker s Compensation Insurance or a certified COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV
copy thereof(Sec 3800 Lab C)
Polity No Company FOR APPLICANT TO FlLL IN AJOB
DDRESS
r-1Certifiedcopy u hereby furnished New Residential Bldgs 8 Poole NO EACH FEE LOCALITY /
r-1Certified copy,is filed with the county building inspection 1&2 Famity, Sq Ft — S $ NEAREST
department Muth family Sq Fl — CROSS ST
Residential Swimming Poole ASSESSOR
Date Applicant MAP BOOT( PAGEPARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS Outlets Rec _Light_Sw MNER OR
COMPENSATION INSURANCE RRM First 20
(This section need not be completed R the work Involved by the Total No Adchbonal ADDREss Or
permit Is for one hundred dollars(5700)or leu) /�
I certify that In the performance of the work for which this permit CITY Tel p 0 - p
is Issued I shall not employ any person In any manner so as to
became subject to the Workers Compensation Lam Ughung Fixtures First 20 APPLICANT
Total
Total No Additional
ADDRESS
Date Applicarrt RESIDENTIAL APPLIANCES NOT OVER 3 HP
NOTICE TO APPLICANT If alter making this Certificate of CITY Tel No
Exemption you Should become subject to the Workers Compensation OTHER APPLIANCES NOT OVER 3 HP
provisions of the Labor Code you must forthwith comply with such PERMIT
provisions or this permit shall be deemed revoked Power Apparatus 8 Large Appliances APPLICANT
LICENSED CONTRACTORS DECLARATION Sized Type HP KWI A or KVAR ADDRESS
I hereby affirm that 1 am licensed under provisions of Chapter 9 '/�/ 10 10 Ind /
(commencing with Section 7000)of Division 3 of the Business and CITU Tel No
Professions Code and my license is in full force and affect Over 10 to 50 Incl
LICENSE Cleo
Over 50 to 100 Ind n.
RED NUMBER
License Number LIo Class Over 100 DISTRICT NO /1v BRED BY O
Services Swbd MCC d Panelboards ✓'�� Q
Contractor Date 0 399 Amp Under 600V DNnL O
DATE
❑ 1 am exempt under Sec 400 1000 Amp Under 800 V / J(7� VALIDATION
Over 1000 Amp or Over 600 V FlNAL W
B 6P C for this reason BRANCH CIRCUIT FEES BY C0
Date 15A or 20A 120V Lighting or Recept Z
1 To 10 Branch Circuits
Signature 11 To 40 Branch Circuits
❑ 41 Or Mare Branch Circuits
Exemption for Rog Mamt Elect 15A 20A 20 VV To ZTN Lighting Br Grcunsi
SINGLE FAMILY Temp Power Pda 8 Appurtenances 2
HOME OWNER BUILDER DECLARATION y
I hereby affirm that I em exempt from the Contractor s License Law `A9^with One Branch Circuit ACCT.r
for the following reason (Section 7031 5 Business and Professions Additional Sign Branch Circuits �Tr17 46.7U
Cptla) J�lllJ
It�VJII I as owner of the property will do the work and the structure Misc Conduits E Conductors 1 1�
Is not intended or offered for sale(Section 7044 Business Other(See Complete Fee Schedule) , TOTAL 46 .70
and Professions Code)
46.74
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the CRAffiE .00
performance of the work for which this permit is Issued (Sec 3097 PERMIT FEE (Sub Totao
Civ C)
PLAN CHECKING FEE 0000-M1 4/19/96
Lender s Name PERMIT ISSUING FEE Q 5973 1 AM 9:18
Lender s Address TOTAL FEE /
I cartity that I have read this application and under penalty of purlury state (�.
that the above information m correct I agree to comply with all County
ordinances and State lame regulating Electrical wiring and hereby authorize
representatives of this County to enter upon the above mentioned property
for Inspedxn purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
�_ F g�
�NATUR PER DATE