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Home My Public Portal About5319 TEMPLE CITY BLVD_Electrical__ WORKERS'COMPENSATIONDECLARATION ; A8APPLICATION FOR ELECTRICAL PERMIT y` ;CE806G 1 hereby affirm that 1 have a certificate of convent to self - COUNTY OF LOS ANGELES BUILDING AND SAFETY insure,or a certificate of Workers'Compensation Insurance or a certified copy thereof(Sec 3800 Lab C) �` c Policy NoCompany FOR APPLICANT TO FILL IN JOB A. ^�rw A& New Residential Bldgs &Pools EACH NO FEE ADDRESS Certified copy u he furnished 1 &2 Family Sq Ft $ — S LOCALITY B/K to f 1 ,61 Certtfled c a filed with the county budding Inspection Multi family Sq Ft CROSS ST sir Y�. o Q/s4e dep at Residential Swimming Pools OWNER OR P'tRIRRRME Etact M wr Det Applicant Outlets Rec_Light Sw _ MAIL first 20 'CERTIFICATE OF EXEMPTION FROM WORKERS Total No Additional - CITY a f --' Tel N.Z79-399 COMPENSATION INSURANCE PLAN CHECK o. (Thu section need not be Completed If the work involved APPLICANT U by the permit u for one hundred dollars ($100) or less) Lighting Fixtures Additiional ADDRESS W 1 certify that m the Total No p y performance of the work for which this - Fixed FApph,u&; Not Over 1 HP CITY Tel No permit u issued 1 shall not employ any person in any manner PERMIT W so, as to become subject to the Workers Compensation Laws Range_ Heater_DW _ App I ANT a e Oven _ Dryer_W M _ ADDRESS ` N Z Date !_T F4_Dphcant Top _ FAU _W H CITY Tel No Hood _ Fan —Other— NOTICL TO APPLICANT If fter making this Certificate of Dup _ Room Air Cond_ I R Exemption you should become subject to the Workers REG NUMBER Class Compensation provisions of the Labor,Code, you must forth Power Apparatus& Large Appliances DISTRICT NO PROCESSED BY with comply with such provisions or this permit shall be _ Size&Type HP,KW,KVA or KVA deemed revoked �/ Up to 1 Incl O` ` Over 1 to 10 Incl FINAL DATE LICENSED CONTRACTORS DECLAROver 10 to 50 Incl AT10 /� �� ` �� VALIDATION I hereby affirm that Iem licensed and tons of Chapter Over 50 to 100 Inc FINAL 9 (commencing with Section 700 Drvuwn 3 of the Bust Over 100 BY news and Professions Code y license is in full force and effect Services License Nr Lm Clan 0-200 Amp Under 600 201-1000 Amp Under 600 V rector Date Over 1000 Amp or Over 600 V HOME OWNER BUILDER DECLARATION Tefnp Power Pole&Appurtenances _ I hereby affirm that 1 am exempt from the Contractor's Sign with One Branch Circuit _ License Law for the following reason (Section 7031 5 Bus, Additional Sign Branch Circuits _ nein and Professions Code) 4 , Mise Conduits&,Conductors �'6 2 9 6 A I. u owner of the property will the work and the Other (See Complete Fee Schedule)— i structure n not intended or offerere d for sale (Section •#'e a'e e e 2 7044 Business and Professions Code) CONSTRUCTION LENDING AGENCY - 2 e e 2 3 5 0 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec 3097 Civ C _ ipERMIT FEE (Sub-Total) 1 2 3 50'- Lender s Name PLAN CHECKING FEE (One Fourth Permit Fee) O 9, 1 7'—8 2 Lender s Address PERMIT ISSUING FEE I certify that 1 have road this application and state that the TOTAL FEE above information is correct I agree to comply with all County ordinances and State laws regulating Electrical wiring and hereby authorize representatives of this County to enter upon the above mentioned property for iM action purposes SEE REVERSE FOR EXPLANATORY LANGUAGE Siphature of Permittee QDate I WORKERS COMPENSATIONcate of cons) 7iA663 Fwsrer APPLICATION FOR ELECTRICAL PERMIT O I hereby affirm shpt I have a certificate of consent to self �a� ` insure or a certificate of Workers Compensation Insurance COUNTY OF LOS ANGELES DEPT -OF PUBLIC WORKS or a certified copy shereof (Sec 3800, Lab C ) ' Policy No V( Company#AfeudON 1T FOR APPLICANT TO FILL IN JOB o Certified copy is hereby furnished New Residential Bldgs 8 Pools rEACHNO FEE �DRE� ) T 6G pLVP Certified copy is filed with the county building inspec 1 8 Family, Sq Ft 1..C�1 S — S LOCALITY Thon deportment Multi-family Sq Ft NEAREST '''' """"�� '��_ Reudentiol Swimmm Pools / CROSS STDote Applicant -�S UM1/� 1.Fi� g OWNER UK MFIRM NAMECERTIFICATE OF EXEMPTION FROM WORKERS Outlets Rec_Light_Sw_COMPENSATION INSURANCE ADDRESS ✓�(This sectfon need not be completed If the work Imohned bT - - _ _ _ First 20 _ - CITY- -'- — '-'-- . Te No = _ '-'--the perrtt9 Is for orisr hundred dollars (SIOO)or Isms) Total No Additional �� PANC KK I certify that in the performance of the work for which this' APPLICANT permit is issued I shall not employ any person in any manner Lighting Fixtures First 20 ADDRESS so as to become subject to the Workers Compensation Laws Additional Date Applicant Total No CITY Tel No NOTICE TO APPLICANT If after making this Certificate of Fixed Appliances Not Over 1 HP PERMIT IKATION L Exemption, you should become subject to the Workers Range_ Heater—DW — Compensation provisions of the Labor Code you must forth- Oven _ Dryer —W M _ ADDRESS *D with comply with such provisions or this permit shall be Top — FAU —WH — deemed revoked Hood _ Fan —Other— CIN Tel No _ LICENSED CONTRACTORS DECLARATION, LICENSE OR I hereby offirm that I am licensed under provisions of Chapter 9 Disp — Room Air Cond REG NUMBER .t r� Class G- i) (commencing with Section 7000)of Division 3 of the Business Power Apparatus 8 Large Appliances DISTR O SSED n d and Profession Code and my license is in full force and effectiq w Size 8 Type HP, KW, KVA or KVAR O License Number��I�uT_Lic Class Up to 1 Incl FINAL V ContractorldJA„1 F1L0A LS$ ate n3- 0-70 Over 1 to 10 Ind DATE; VALIDATION 0O OOver 10 to 50 Incl FINAL V I am exempt under Sec Over 50 to 100 Inc BY W B 8P C for this reason Over 100 i 11 Services Swbd , MCC B Ponelboards , W Date Z 0-200 Amp Under 600 V Signature ,I. :4 ” Z O 201 - 1000 Amp Under 600 V ❑ Exemption for Reg Mont Elect O.er 1000 Amp or Over 600 V ' SINGLE FAMILY Temp Power Pole 8 Appurtenances 2 HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit y hereby affirm that am exempt from the Contractor's License Additional Si n Branch Circuits AC(T.V Law for the following reason (Section 7031 5, Business and g Professions Code) 3307 138.6.1 ❑ I as owner of thero Min Conduits 8 Conductors 1 ITM p party, will f o the work and the Other See Complete Fee Schedule structure not intended or offered for sole(Section 7044 ( P PisTOTAL - 138. 60 Business and Professions Code) CONSTRUCTION LENDING AGENCY CHECK 138561] I hereby off irm that there is a construction lending agency for the performance of the work for which this permit a issued PERMIT FEE (Sub-Total) GHAT ,VI (Sec 3097, Civ C ) , PLAN CHECKING FEE Lender's Name / I 0000-Mi IV 3/913 PERMIT ISSUING FEE Lender s Address TOTAL FEE 9+436 1 AM11:57, 1 certify that I have read this application and state that The above information is correct I agree to comply with all County , ordinances and Stale laws regulating Electrical wiring and hereby authorize representatives of this County to enter upon ' the above mentioned property fee inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE 'Signature of Permittee to L WORKERS COMPENSATION DEto of r ION �aato =/� APPLICATION FOR ELECTRICAL PERMIT Q I hereby affnm Mal f bolts a ceniffate 9f rpnsent to sell �� insure or a certificote of Workers Compensation Insurance COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS or a candied copy thereof (Sec 3800, Lab C ) P dW No— Company FOR APPLICANT TO FILL IN !OB ../ Certified copy Is hereby furnohed New Residential Bldgs 8 Pools ' EACH HO FEE ADD Certified copy rs filed wt eco ry buddm I ec- 1 8 2-Famdy, Sq Ft - S. ' — $` LOCALIT`A - tion..department Multi family Sq Ft — NEAREST Date ••rrlOR Residential Swimming Pools CROSS RST APPi IRM NAME CERTIFICATE OF EXEMPT N FROM WORKERS ' Outlets Rec_Llght_Sw_ MAIL _ COMPENSATION INSURANCE ADDRE 1016-1 _(This section need not be completed If the work Involved by Total No - Additional 0 , CIN Tel the penn8 Is for one hundrid dollars ($100)or Ins) I certify that In the performance of the work for which this '1 PIAN CHECK permAPPLICANT soso as t I Is Issued, I shall not employ any person in any manner Lighting Fixtures First 20 ADDRESS as to become subject to the Workers Compensation Laws 9 n0 AdditionalDote Applicant Total No CITY Tel No NOTICE TO APPLICANT If after making this Certificate of Fix Total Appliances Not Over 1 HP PERMIT Exemption you should become subject to the Workers Range— Heoter_D W — APPLICATION v �� Compensation provisions of the Labor Code you must forth- Oven — Dryer —W M _ ADDRESS with comply with such provisions or this permit shall be To FAU _WH _ - deemed revoked Hood —Other— CIN HooTel LICENSED CONTRACTORS DECLARATION Hoo — Room Air Cord — LICE - Class I hereby affirm that I am licensed under provisions of Chapter 9 REG NUMBER (commencing with Section 7000)of Division 3 of the Business Power Apparatus 8 Large Appliances DISTRICT NO -/ SSE } and Profession Code,and my license Is In full force and effect - - — y d Size 8 Type HP KW, KVA, or KVAR o Q License Number Lic Class— - f.J Up to 1 Incl FINAL Over 1 to 10 Incl DATE l III VALIDATION cr Convector ^^ta � Over 10 to 50 In � tl FINAL I am exempt under Sec Over 50 to IOD Inc - BY w B 8P C for this reason Over 100 - d ► N Date - Services Swbd , MCC 8 Ponelboords _ Z 0-200 Amp Under 600 V Signature 201 - I000 Amp Under 600 V Over 1000 Amp or Over 600 V Exemption for Reg Mamt Elect SINGLE FAMILYTemp Power Pole 8 Appurtenances _ _ 2_ HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit I hereby affirm that I am exempt from the Contractor s License ACCT,: Law for the following reason (Section 7031 5 Business and Additional Sign Branch Circuits Professions Code) 3307 25.511 .511 ❑ 1, as owner of the property, will do the workand the Mix Conduits 8 Conductors 1 ITM structure Is not Intended or offered for sale(Section 7044, Other(See Complete Fee Schedule)-- Business and Professions Code) TOTAL 25. 50 CONSTRUCTION LENDING AGENCY C CK 255.50 1 hereby affirm that there Is a construction lending agency for the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) r M (Sec 3097, Civ C ) PLAN CHECKING PERMIT ISSUING FEE 0000--0001'FEE Lender s Name 12/27/39 r Lenders Address _7784 1 AM 9:03, 1 certify that I have read this application and state that the TOTAL FEE above information is correct I agree to comply with all County ordinances and State laws regulating Electrical wiring, and - hereby thorize representatives of this County to enter upon ' the ve m n n purposes SEE REVERSE FOR EXPLANATORY LANGUAGE s Chr iZ ' mr Ignature of Per nee Dote