HomeMy Public PortalAbout5713 TEMPLE CITY BLVD_Electrical__ Wm that I have
a certificate
DECLARATION 7eae83 ,D,e, APPLICATION FOR ELECTRICAL PERMIT {�
I hereby 91hrm that I have a cerlitinata of consent to self insure �9080 �J
a a certificate of Workars Compensation Insurance or a certified!• COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof (Sec 3800 Lab C)
Pducy No Company FOR APPLICANT TO FGL IN JOB
ADDRESS
c `/
❑ Certified copy is hereby furnished New Residential Bldgs &Pods EACH NO FEE
F1 Certified copy is filed with the county budding inspection 1 8 2-Femiy Sq Ft $ _ $ LOCALITY
department Mdti-famry CROSSST
Ft ROSSNEARET
CSf - A-
Date App4K t Resdontal Swimming Pools MNER OR
FIRM NAME QAC
CERTIFICATE OF EXEMPTION FROM WORKERS Outlets Rec—Light — Sw ADDRESS 66 /T
COMPENSATION INSURANCE
(This section need not be completed If the work lmot ad by the First 20
permit is for one hundred dollars($100) or lees) Total No Additional CITY _ CIO do Tel No ��
I certify that in the performance of the work for which this permit ; / _ r I PAPPUCAW
LAN CHE K
is issued I shall not employ any,person in any manner so as to
become subject to the Workers Compensation Laws Lighting Fixtures First 20� I ADDRESS -
f� ,/ i
/U�d-!`�� Total No Addrtnnal v CITY Tel No
Date Applrcant� FMI
ixed Appliances Not Over 1 HP PERT
NOTI TO APPLICANT If after making this Certrf eta of APPLICANT 1414WIAWn
Exemption you should become subject to the Workers Compensation Range_ Heater_ DW
provisrons of the Labor Code you must forthwith comply with such Oven _ Dryer _ W M _ ADDRESS
provisions or this permit shall be deemed revoked Top _ FAU _ WH
CITY Tel No
LICENSED CONTRACTORS DECLARATION Hood — Fen Other_
I hereby affirm that I am licensed under prows,ons of Chapter gDip jioorn Air(;per LICENSE OR Class
(commencing with Section 7000)of Drwson 3 of the Business aridREG NUTASER
Professions Code and my license is in full to"and effect Power Apparatus& Largo Afap4u es - DISTRICT NO PROCESSED BY �yN
Size& Type HP KW KVA or KVAR � E
License Number Lc Class Up to 1 Ind FINAL -
O.er 1 to t0 incl DATE VALIDATION IX
Contractor Date Over 10 to 50 Ind
❑ BY
FINAL
I em exempt under Sec Over 50 to 100 Inc BY
ty
B&PC for this mason Over 100 N
Services Swbd MCC&Panelboerds
Date 0-200 Arty Under 800 V
Signature 201 - 1000 Amp Under 800 V
❑ Over 1000 Amp or Over 800 V
Exemption for Reg Mamt Elect
SINGLE FAMILY Temp Power Pole& Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Cncun
I hereby off=that I am exempt from the Contractors Lcen se Law
far the following reason(Section 7031 5 Business and Professions Additional Sign Branch Circuits
lCo�de)/ rK-1
LJ Its owner d the property will do the work and the structure � Conduits& Conductors `307 31.V V
is not intended or offered for sale (Section 7044 Bus muss Other (See Complete Fee Schedule) 1 ITEMSITEMSPoo.and Professions Code)
CONSTRUCTION LENDING AGENCY TOTAL 31 . 00
1 hereby affirm that there is a construction forcing agency for the CHECK31.Vtl
ance oPERMI
performance the work for which this permit is Issued(Sec 3087 T FEE (Sub-Total)
Civ C) (' .DD
PLAN CHECKING FEE ,
Lenders Name
PERMIT ISSUING FEE 3
Lenders Address - DOOD-DD01 9/ 4/90
1 certify that I have read this application and state that the above TOTAL FEE �� 2
Information is correct I agree to comply with all County ordmances - 2fk0n0+ 1 AI111�1`
and State lam regulating g Electrical wrong and hereby authonze
representatives of the Canty to enter upon the abo�rnentroned
propyq for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
9 a .
Signature of rmitt" Date ,� - --