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HomeMy Public PortalAbout5423 TEMPLE CITY BLVD_Electrical__ r )YORKERS COMP#wN DECLARATION 76A663 10/8I *ereby"iEifum that 1 h6vidiaate of consent to ,elf cEaoeG APPLICATION FOR ELECTRICAL PERMIT msure or a certificate oflilt s Compensation Insurance COUNTY OF LOS ANGELES BUILDING AND SAFETY or a certified copy thereof(Sec 3800, Lab C Policy No -Company / Q FOR A/►LICAM 70 FILL IN ❑ Certdied copy is Lereby furnished 1/IAA�, New Residential Bldgs 8 Pools EACH NO FEE SS 7 Vb 1d Certified copy is filed with the county budding inspe< 1 8 2-Family Sq Ft f — f LOCALITY bonI'ment ' Multi-family Sq Ft — NEAREST CROSS ST 2 N Residential Swimming Pools i 1 Date Applicant S V • _ •• FIRM AME 1 CERTff TE OF EXEMPTION FROM WORKERS Outlets Rec-L—Ltght_Sw_ MAIL COMPENSATION INSURANCE Fat 20 r '� '� ADDRESS (This settlors need not he completed If the work Involved by - the permit Is for one hundred dollen($100)or less ) Total No 51 Additional CIT Tel No CHECK I certify that in the performance of the work for which this PIANAPPLICANT permit is issued I shall not employ any person in any manner so as to become subject to the Workers Compensation Laws Lighting Fixtures Fiat 20 ADDRESS Total No Additional CITU Tel No Dote Applicant Fixed Appliances Not Over 1 HP - PERMIT NOTICE TO APPLICANT If after making this Certificate of �/ PERMIT T Exemption, you should become subject to the Workers Range_ Heater_D W Compensation provisions of the Labor Code you must forth Oven _ Dryer _W M _ ADDRES with comply with such provisions or this permit shall be To _ FAU _W H deemed revoked Hood --7 Fon _Other_ Cl vw TI/No 16-2-3115 CONTRACTORS DECLARATION Disp JL Room An Caird f w UOQ OR Class C�1 I hereby affirm that 1 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 BY d and Professions C e and my license is in full force and effect Size 8 Type HP KW KVA or KVAR v•V License Nu tier Lit ClassC-10 Up to 1 Incl FINAL G' Over 1 to 10 Incl DATE ""v �� LIDATION O Connect ASUJto Over 10 to 50 Incl FINALW ❑ I am exempt under Sec Over 50 to 100 Inc BY d B 8P C for this reason Over 100 Z Date Services Swbd MCC 8 Panelboards 0 -200 Amp Under 600 V Signature 201 - 1000 Amp Under 600 V ❑ Exemption for Reg Mainr Elect Over 1000 Amp or Over 600 V SINGLE FAMILY Temp Power Pole 8 Appurtenances 11 7 4 HOME OWNER BUILDER DECLARATION Sign with One Branch Circuit I hereby affirm that I am exempt from the Contractor's License Additional Sign Branch Circuity Law for the following reason (Section 7031 5 Business and Professions Code) p 5 2 9-8 6 ' ❑ I as owner of the property will do the work and the M sc Conduits 8 Conductors structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ ► 7044 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 ) PIAN CHECKING FEE Lender s Name PERMIT ISSUING FEE 16 Lender s Address I 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 hereb Ry authorize representatives of this County to enter upon t o mentioned for inspection Pur SEE REVERSE FOR EXPLANATORY LANGUAGE A .5LZ.7 Signature of Permittee —/Date '