HomeMy Public PortalAbout5417 TEMPLE CITY BLVD_Electrical__ WORkER S COMPENSATION DECLARATION 20-0019 DRV 9109
I ;ereby adirm-that I have a certificate of consent to self insure 76AG3 APPLICATION FOR ELECTRICAL PERMIT
or a certificate of Worker a Compensation Insurance or a certified COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV
copy hereof(Sec 3800 Lab C)
"-❑Policy N. Company FOR APPUCAxT TO RLL W'-
1:1
CenlOsd copy Is hereby furrYeMd New Residential Bldgs $Pools EACH NO FEE '
❑ Certified copy Is filed with the county bustling Inspection 1 8 2-Family SQ Ft - '�� $ — $ LOCALT'
department Num-faintly Sq Ft - ��gy
Date Appllcanl Residential Swimming Pools l ASSESSOR
��7y 9w ASP BOOK PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS _ p �
COMPENSATION INSURANCE _ Outlets RetLlghlJ First 20 - �t7 D Few URE
(This seef on need not be Completed If the work Involved by the //
permit Is for one hundred doUsrs($100)or less) Total No AddlOonal AD0He98 �rs7?y/
1 certify that in the performance of the work for which this permit CITY S--Z r E . Tel No
le issued I shell not employ any person In any manner so as to
become subject to the Workers Compensatlon Laws Lighting Fbdures Fuad 20 17,0ADWC. - _-
t , Total No Additional
ADDRESS
Data APP ant 15 OR 20A,12UV BRANCH CIRCUITS
NOTICE TO APPLICANT R after making title Cerfifica of DITY Tel f0-
Exemption you should become subject to the Workers Compensation t TO 10 INCLUSIVE EACH
provisions of the Labor Code you must forthwith comply with Such 11 TO 40 INCLUSIVE EACH - - PEtarIT
Provisions or this permit shall be deemed revoked 41 OR MORE BRANCH CIRCUITS EACH APPLICANT
LICENSED CONTRACTORS DECLARATION -� ADDRESS-
15 OR 20A 20811 TO 277V LIGHTINGLIGHTINGEA
NO EACH - d
I hereby affirm that I em licensed under provisions of Chapter 9
(commencing with Section 7000) o1 Division 3 of the Business and r _ _ __ CITY _ _ - Tel W
Professions Code and my license IS In full force and effect RESIDENTIAL APPLIANCES UP TO 3HP LNXNSE ORam
Poser Apparatus 8 Large Appliances RE( NUMB R 0
I"Number Lio Clens Slze 8 Type HP,KW HVA or KVAR d3TRlci NO - PI=ESSm BY F
_. Upto31nc1
Contractor paleOver 3 to 10 Incl - FINAL G d
I Over 10 to 50 Incl �� N
❑ I am exempt under Sec _ Over 50 to 100 Ind VALIDATION ?
B&P C for this resin - Over 100 __ _ _ e INAL _
Benicia; ite
Sd MCC&Peidboards
Dau 0 200 Amp Under 900 V _ rV
Signature 201 1000 Amp UMer800V
E-1Exemption 0-r Reg Mem Elect - O+er 1000 Amp a Over 800 V
SINGLE FAMILY Temp Power Pale$Appurtenances l
HOME OWNER BUILDER DECLARATION - - t
I herby affirm that I on exempt from the Business
a License Lew
Sign with One Branch Grwu I +T
la the following reason(Section 7031 5 eusinesa and Professions Additional Sign Branch Ckalib �-1�� ryp =c
I u owner o1 the property will do the work and the ewcture Mtec Candunn A Conductors i _TEiG
is not Intended or offered for sale (Section 7044 Business Other(See Complete Fee Schedule) , i�1TRL !9 - 55
and Professions Code) ' ' CHEr'i c$,S5
:
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the
performance of the work for which this permit 4 issued(Sac 3097 PERMIT FEE (Sub-Total) 3 Q
Ch, C)
PLAN CHECKING FEE ,
Lender a Name --77 'L - `
PERMIT IN FEE" O�7 _ -K79 i 0 1 i�i;•
Lender a Address TOTAL FEE S
I certify that I have reed this application and erste that the above _
information Is correct I agree to comply with all County.,.,,.antes
and State lawn regulating Electrical wiring and hereby authorize
representatives of this County to enter upon the above mentioned
property To 1 pectin Pur ogee ,/ BEE REVERSE FOR EXPLANATORY LANGUAGE
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6gNATU OF TOR HT 11