HomeMy Public PortalAbout5504 TEMPLE CITY BLVD_Electrical__ WORKERS COMPENSATION DECLARATION CE 800 10,81 APPLICATION FOR ELECTRICAL PERMIT
I hereby AXvm that I have a certificate of consent to Bell insure �eaeO
or �ertdcafe of Workers Compensation Insurance or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
(day 3000 Lab C)
Pc4IWNo Company FOR APPLICANT TO FILL IN JOB
❑ CeNfied coPY a hereby turnahed New Residential Bldgs fl EACH NO FEE. AcolaEss
❑ Certified copy is filed mth the county building inspection 1 d 2-Family So Ft 1115�Po $ — $ LOCALITY
department Multi-family So Ft — �EST
CROSS S
Data Applicant Residential Svnmmng Pools IER OR /• I,
CERTIFICATE OF EXEMPTION FROM WORKERS � Mpn NAraE i CS R,
Y
COMPENSATION INSURANCE Outlets Rec Light Fuss 20 D 8 ADDRESS
(Tho section need not be completed It the work urvolved by the Total Airst 20 l Tel No
I IV
permit Is for one hundred dollars($100)or less)
I certify that in the performarce rn the work for which this permit LOW
E11
issued I shall not employ, any person in arty manner so as to APPLICANT
become subject to the Workers Compensaton Lawn Lighting Fixtures First 20 av ADDRESS _
Total No �� Additional
Date lico
Appnt CITY Tel No
NOTICE TO APPLICANT If after making this Certificate of Fixed AppliancesNot Over 1 HP PEJ11nfi
Exemption you should become subject to the Workers Compensation Range Heater_ OW x APPLIGINT G �G.l%+-�
Provremns of the Labor Code you must forthwith comply with such Oven L Dryer _ W M _ , ( OL ADDRESS
o '
prowsns or this Permit shall be deemed revoked Top — FAU _ W H _ 7 CITY - Tel No
LICENSED CONTRACTORS DECLARATION Hood — Fan _ Other_
I hereby affirm that I am licensed under prwanons of Chapter B Disp X— Room Air Cord LGENSE OR
(commencing with Section 7000)of Dwaion 3 of the Business and REO NUMBER Gass
Professions Code and my license a in full force and effect Prover Apparatus E Large Appliances DISTRICT NO D BY
Size 8 Type HP KW KVA or KVAR —5,—p e LGyL.[.t o
License Number L, Class Up to 1 Ind FINAL 8
Over 1 to 10 Incl DATE
Contract Data 2-7 -1 VALIDATION p
or Over 10 to 50 Incl
❑ FINAL
I em exempt under Sec Over 50 to 100 Inc gy
BBPC for this reason Over 100
Services Swbd MCC 8 Panelboards ►
Date 0- 200 Amp Under 600 V Z
Signature 201 - 1000 Amp Under 600 V
❑ Exemption for Reg Mamt Elect Over 1000 Amp or Over 800 V
SINGLE FAMILY Temp Power Pole 8 Appurtenarcxa '1
HOME OWNER-BUILDER DECLARATION Sign with One Branch Cucun
1 hereby affirm that I em exempt from the Contractors i-cerise Law Sign wtel One
ranch Grcuits Al4T.i
for the following reason(Section 7031 5 Buameas and Prdeseora
Cade) 707 24.60
a9 owner of the property will do the wk and the structure �� Conduits 8 Conductors
or
is not intended or offered for sale (Section 7044 Business Other (See Complete Fee Schedule) _ 1 ITEM
and Professions Code) TOTAL 84. 60
CONSTRUCTION LENDING AGENCY C. Ecyl 24.60
1 hereby affirm that there re a construction lending agency for the X011
performance of the work for which this permit 0 issued(Sec 3087 PERMIT FEE (Sub-Total)
Cv C)
PLAN CHECKING FEE _
Lenders Name I�IO-0001 1/23/91
PERMIT ISSUING FEE
Candace Address 5143 - 1 AM E:17
1 certify that I have read this application and state that the above TOTAL FEE (O
information is correct I agree to comply vnth all County ordinances
and State laws regulating Electrical wlnng and hereby authonze
rspresentahv 1 the Coon iter upo above-rtlanhoned
paPertY fie action pu s /
SEE REVERSE FOR EXPLANATORY LANGUAGE
r of Permit Date