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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