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Home My Public Portal About5349 TEMPLE CITY BLVD_Electrical__ WORKERS COMPENSATION DECLARATION 7snes3 rD,B, APPLICATION FOR ELECTRICAL PERMIT I hereby affirm that I have a certliKAte of cbreenl tosell Insure �eceO � a a certificate of Workers Compensator Insurance or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY C) Canpany /� FOR APPLICANT TO FILL IN JOB ADDRESS Certdred copy re hereby furnished New Residential Bldgs d Pods EACH NO FEE 1 8 2-Family SO Ft $ — $ LOCALITY, f �ggrttood''iVVedrerepptwtPy is bled vnth the /county bw/ldlrg InsApectwn Multi-famiy SO Ft — NE EST /Date' Applicant is J� ✓��• Residential Swimming Poo CROSS �R OR 94 CERTIFICATE OF EXEMPTION FROM WORKERS j,I(yls�I FIRM NAA ' COMPENSATION INSURANCE Cutlets Rec�Light 4. Sw & � / O MUL (This section need not be co First 20ADDRE� completed H the work Imohetl by the Total No Additional CITY Tel No permN Is for one hundred dollars(5100)or lees) I certify that In the performance of the work for which this permit 'PLAN CHECK is Issued I shall not employ any person In any manner so as to APPLICANT become sub)ect to the Workers Compensation Lase Lighting Fixtures`/ Frst 20 L ADDRESS Total No Additonel Date Applicant CITY Tel No NOTICE TO APPLICANT If after making this Certdlcate of Fixed Applpnces Not Over 1 HP PERS Exernp on you should Wor become subject to the kers Compematon Range_ Heater_ OW _ _ ANT onooslorm of the Labor Code you must forthwith comply with such Oven — Dryer — W M — ADDRESS prowaons or this permit shall be deemed revoked Top — FAU WH — LICENSED CONTRACTORS DECLARATIONCITY I N Hood — Fen � Other_ ommeI hereby ing that I am licens7000) under n3oftprovisions B Chapter d LICENSE OR (commencing with Sector 7000)01 DNpon 3 of the Business end DIaP — Room Nr Cord REO NUMBER Civ Cl� Professions Code and my 1x Is In full force and effect power Apparatus X Large Appliances DISTRICT NO PROCESSED Size E Type HP KW KVA on KVAR 0� « O - Lcense Number �� - 8 Lc Close Up to 1 Incl FINAL y Over 1 to 10 1=1 DATE _ VALIDATION Contractor Date 3 / 9 Over 10 to 50 InclFl F Elam exempt under Sec - NAL Over 50 to 100 Ino BY BBPC for this reason Over 100 9,1.iqN Data Services Swbd MCC&Panelboards , Z 0- 200 Amp Under 000 V Signature 201 - 1000 Amp Under 000 V ❑ ExemptOver 1000 Amp or Over 000 V Exemption for Reg Mamt Elect SINGLE FAMILY Temp Power Pole d Appurtenances '} HOME OWNER-BUILDER DECLARATION Sign with Ore Branch Cuoud 1 hereby affirm that I am exempt hcm the Contractors License Law Additional with Sign ranch Circuits CT•T for the tolbwmg reason (Section 7031 5 Business and Professions g Done) 3307 39.60 ❑ Mlsc Conduits& Conductors _ 1 ITEMS I as owner of the Property will do tie work and the structureBusiness Other(See Complete Fee Schedule) — a not Professions C offered for sale (Becton 7044 Business � TOTAL 39 - 60 and Professans Code) ' CONSTRUCTION LENDING AGENCY [HECK 37.60 1 hereby affirm that there is a cormitfuction lending agency for the performance d the work far which this permit is Issued(Sec 3087 PERMIT FEE - CHANGE al Cw C) (Soh-Total) PLAN CHECKING FEE Larders Name 0000-00191 10/10/90 PERMIT ISSUING FEE Lenders Address 3228 1 Ah 10:45 tartly I have read thea epplpaten end state that the above TOTAL FEE 6 Infonnat, correct 1 agree to comply with all County ordinances end St laws regul real mrinlg and hereby autth ze nepre nes Of to entM upon the above-mentioned for ins t es � SEE REVERSE FOR EXPLANATORY LANGUAGE Sgnatureof FeMIR Pre Date U ,t WORKERS'COMPENSATION DECLARATION CE863 1081 APPLICATION FOR ELECTRICAL PERMIT �I hereby yffvm that I have a certificate ote of consent to self 06G i insure p&p certificate of Workers Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY of a certified copy^thereof (Sec 31100 Lab C ) Policy No QZ, 7 1LCompony 19 FOR APPLICANT TO FILL IN ADDRESS _ p,KG/ L Certified copy a hereby furnished New Residential Bldgs 8 Pools EACH NO FEE (s'G Certified copy is filed with the county building tnspec 1 8 2-Family, Sq FI $ — S 10 LOCALITY hon department Multi family Sq Ft — 0. S5T OG T Dote n ppl¢ont 4 q,09DWr/ Residential Swimming Pools OWNER OR /•1/ j,(JA CLAc FIRM NAME lV/V _ CERTIFICATE OF EXEMPTION FROM WORKERSOutlets RecMAIL G... COMPENSATION INSURANCE First 20 ADDRESSL�ghtsw, c-17 r (This section need not be complatad H the work Involved by1 1 Total No Additional CIN gN -G -� Tel Not j mff 7�d the porIs for one hundred dollars ({100)or lass) RAN CHECK p ^ I certify that in the performance of the work for which this APPLICANT W� permit is issued, I shall not employ any person in any manner so os to become subject to the Workers Compensation Lows Lighting Futures First 20 ADDRESS Total No [s// Additional CITYel Nol� r5 Dote Applicantfs NOTICE TO APPLICANT If after making this Certificate of Fixed Appliances Not Over 1 HP PERMIT e_ Heater_D W _ APPLICANT Exemption you should become subject to the Workers Range Ij Compensation provisions of the Labor Code you must forth Oven _ Dryer W M _ ADDRESS,91 with comply with such provisions or this permit shall be Top _ FAU _WH _ deemed revoked 1 I Hood _ Fan _Other— CITY Tel No LICENSED CONTRACTORS DECLARATION LICENSE OR I hereby affirm that I am licensed under provisions of Chapter 9 Disp _ Room Air Cond REG NUMBER Clan (commencing with Section 7000) of Division 3 of the BusinessDISTRICT NO Y and Professions Code and my license is in full force and affect Power Apparatus 8 Large Appliances ./ Size 8 Type HP KW KVA or KVAR `p Q License Number L,c ClassUp to I Incl - ' FINAL V Over I to 10 Incl DATE V IDATION 0 Contractor DateOver 10 to 50 Incl ElFINAL I am exempt under Sec Over 50 to 100 Inc BY d B 8P C for this reason Over 100 11,7 = Dote Services , MCC d Panelboards ► / — 0 -2000 Amp Under 600 Signature 201 - 1000 Amp Under 600 V ❑ Over 1000 Amp or Over 600 V Exemption for Reg Moral Elect �813 4 A SINGLE FAMILY Temp Power Pole 8 Appurtenances _ HOME OWNER BUILDER DECLARATION Sign with One Branch Circuit • • • a • 2 1 hereby affirm that I am exempt from the Contractor s License Low for the following reason (Section 7031 5, Business and Additional Sign Branch Circuits _ ( • - 21..00 Professions Code) • o!921.005 ElI as owner of the property will do the work and the Mix Conduits 8 Conductors - structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ ) 01 6-87 70M Business and Professions Code) CONSTRUCTION LENDING AGENCY - I 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) _ -- (Sec 3097 Civ C ) PLAN CHECKING FEE Lander s Name PERMIT ISSUING FEE ff) LM Lender s Address / 0 I candy that I have read this application and state Ihat the TOTAL FEE above information is correct I agree to comply with all County ordinances tote laws regulating Electrical wiring and hereby a or a repres olives of this County to enter upon thea a noon ry for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE IF I/D706_y 1 n ure of Per Date