HomeMy Public PortalAbout5226 TEMPLE CITY BLVD_Electrical__ WORKERS COMPENSATION DECLARATION 7 A%3 DPW(,2 a„ APPLICATION FOR ELECTRICAL PERMIT lJ
I hereby affirm That I have a certificate of consent to Bell matins
or a certificate of Worker a Compensation Insurance or a certified COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV
copy thereoc f(Sec 3800 Lab C)I ..- , y -
Policy No Company FOR APPLICANT TO Fa.L IMS I r
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Certified copy Is hereby furnished New Residential Bldgs &Pools NO EACH FEE LOCALITY LF/
❑ Camped copy is filed with the county building Inspection i 8 2 Family Sq Ft $ N EST
r department , IMulti family Sq Ft GRDBB Si
lop-
Date Applicant Residential Swlmming Pods ASSESSOR
MAP BOOK PAGE PMtcm
CERTIFICATE OF EXEMPTION FROM WORKERS I Outlets Rec Light SwIRMER()R
WA
COMPENSATION INSURANCE First 20 - _
(This section nee14w les may,
d not be completed If the work Involved by the Total No Additional AWRESS ( Cl
permit Is for one hundred dollars(5100)or leu)'
I certify that in the performance of the work for which this permit - CITY - NO ytf�?,c y-y 0
is issued I shall not employ any person In any manner so as to PUN CHECK
become Subject to the Workers Compensation Laws Lighting Fixtures First 20 Appt.ICAM
Total No Additional
ADDRESS
Date Applicant RESIDENTIAL APPLIANCES NOT OVER 3 HP
NOTICE TO APPLICANT If after making this Certificate of CITY TN W
Exemption you should became subject to the Workers Compensation OTHER APPLIANCES NOT OVER 3 HP PERMIT �
provisions of the Labor Code you must forthwith comply with such A CCANr P/w��
provisions or this permit shell be deemed revoked Rower Apparatus 8 Large Applu n:es
I LICENSED CONTRACTORS DECLARATION Size 8 Type HP KW KVA or KVAR ADDRESS
I hereby affirm that I am licensed under provisions of Chapter 9 Over 3 to 10 Ind
(commencing with Section 7000) of Division 3 of the Business and CITY TN No
Professions Code and my license Is In full force and effect Over 10 to 50 Incl LICENSE of _ }
Over 5010100Ind REG NWBER Cm O
L"nst,Number LIc Gass Over 100 DISTRICT NO P SSED BY V
— brae Swbd 8 � ifs x_57 D . cr
Contractor Date ( d r V ��
E] I em exempt
under Sec 400 1000 Amp Under 600 V R /v /v a
Over 1000 Amp or Over 600. V VALIDATION
B APC for sties reason BY ? Z
BRANCH CIRCUIT FEES
Date 15A or 20A 120V Lighting or Recept ALCT.i
Signature 1 To 10 Branch Orcuna
9 - 11 To 40 Branch Circuits .�, ., �C•4 J
41 Or More Branch Circuits rrld�
❑ Exemption for Reg Maint Elect 15A 2ak 208V To 277V UOUng Br Cmuts
SINGLE FAMILY Temp Power Pole 6 Appurtenances TOTAL 63 - 45
HOME OWNER BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor a License Law CHECK Sign with One Branch Circuit 67 ry
K. .,t
f following reason (Section 7031 5 Business and Professions Addron it Sign Branch Circuits CHN4TVG
IV
/ _Code) I as owner of the property will do the work and the structure Mies Conduits 8 Conductaa 'IVG
is not intended or offered for sale (Section 7044 Business Other(See Complete Fee Schedule) ,• VqUV-tJUL!1 10/12/9,tand Professions Code) _ _
CONSTRUCTION LENDING AGENCY 7-2,3I 1 AM 908
1 hereby affirm that there is a construction lending agency for the
performance of the work for which this permit is issued(Sec 3097 PERMIT FEE (Sub Total 3
CIV C)
PLAN CHECKING FEE
Lender a Name
PERMIT ISSUING FEE
Lender a Address TOTAL FEE
I certify that I have read this application and under penalty of pudury stele
that the above informauon IS correct I agree to comply with all County
ordinances and State laws regulating Electrical wiring and hereby authorize
represantamves of this County to enter upon the above mentioned property ,
(\ for mspectlon purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
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