HomeMy Public PortalAbout5039 TEMPLE CITY BLVD_Electrical__ WORKERS COMPENSATION OECLARATTON 7BA863 10/81 J1
I hereby affirm that, have a ceriJKate of consent to self insure, GES APPLICATION FOR ELECTRICAL PERMIT IIL,II
or a certificate of Workers Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
coq thereof(Sec 3800 Lab C) I L I
PollCy No ' Company FOR APPLICANT TO RLL IN JOB ,I 2
❑ Certified cois hereby furnished New Residential Bldgs & feels EACH NO FEE ADDRESS 0,3 Z-'-I (��.� L✓�
q
r❑ 1 & 2-Family Sq Ft S — S LOCALITY
CertA,atl coq .s hletl,whh the caun Iduig inepecbon
department - Multi-family Sq Ft — N ESST ZA OS
Dale , Applicant Residential Swimming Pools OM NAME r
2 /^/ , O r
` CERTIFICATE OF EXEMPTIO FROM WORKERS , Outlets Rec_3 Light�L Sw —�` �
COMPENSATION SURANCE ' - -3 ADDRESS G
(This section need not be co ed N the work Irwofved by the First 20 ,
permit Is for one hundred d re IStoo)or bee) Total No Addihwial, CITY C - Tel No
I certify that In the performa of the work for which this Ipermit r PIAN CHECK
Is issued I shell not any person In any manner_so as to APPLICANT
become subject to 1 ars CanpensatKn Lighting Fixtures First 20 ADDRESS
Total Noy Additional
Data cent CITY - Tel No
NOTICE TO APPUC If after meld t CerlJcale of Fined Appiarcee Not Over 1 HP' PERMT Izz
xemp ion you atcud me subject to the Compensation Range_ Fleeter_ DW _
prwnsims of the Labor a you must brt ply with such Oven Dryer_ WM _ ADDR %t Vis
wowuons w this permit I be tlaen�d Top FAU _ WH
IJCENSED fJTRACTORS DECLARATION GIT ' ' fb
Hood — Fan _ Other_
hereby affirm that I a licensed under prov,scns of Chapter 9 LICENSE O
(commencug with Sed 7000) of Division 3 of the Busmess and DLSA — Room Nr Cxvid REG NUMBER CJeee
Professions Code end license a In full face and eNacl Power Apparatus& Large Appliances DISiRCT NO ESSED
Sae& Type HP KW KVA or KVAR J . O U
Lceree Number Lc Close Up to 1 Incl FINAL
Contraclw - Date Ovar Ito Wire] DATE VALIDATION 0
Over 10 to 50 Ind FINAL
❑ I am exempt Sec Over 50 to 10O Inc By
B&PC fo 1 is reason Over 100
N
Services 20MCG 8 r 600oerd9 ► Z
Date 0- 2000 Amp Under 800 V r'
Sgne 201 - 1000 Arty Under 600 V _
❑ Over 1000 Amp or Over 800 V
E ion for Reg Maint Elect
SINGLE FAMILY Temp Power Pole& Appurtenarcea 2
HOME OWNER-BUILDER DECLARATION Sign wdh One Branch Circuit w�vNT a
I hereby affirm that I am exempt tram the Contractors License Law17bH1•T ¢
for the) following reason(Section 7031 5 Business and Professions Additional Sign Branch CirculIis ' _ 1J 75
' Misc Conduits& Conductors - ITEMS
I es owner of the property wnfl do the•cork and the structure Other(Sea Complete Fee Schedule) _
is net intended a offered for sale (Section 7044 B1rsvleas
and Probssions code) - POP. TyvOL�TAvW�Ly 15.75
CONSTRUCTION LENDING AGENCY ' CHE(z 15.7
1 hereby affirm that there Is a construction lending agency for the cwpa •00
performance of the work for which this permit is issued(Sec 3087 _ PERMIT FEE r (Sub-Total)
Civ C)
•( O U PLAN CHECKING FEE 1 � �
Lenders Nar11e AJ
Lenders Address' PERMIT ISSUING FEE _ i d 4187 1 AMID58
I certify that I have mad this application and state that the above TOTAL FEE �� 7
Information Is correct I agree to comply with all County ordinances "
and State lacca regulating Electrical wring and hereby authorize '
representatives of this Coun to enter upon the above-menbered
props fa ms s y /o _
SEE REVERSE FOR EXPLANATORY LANGUAGE
Sgnatu of mat Date