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Home My Public Portal About5722 A-E TEMPLE CITY BLVD_Electrical__ WORKERS COMPENSATION cafeDECLARATIONcorse �"00190PiVsr�� APPLICATION FOR ELECTRICAL, PERMIT Q • sFherpby dff.rrF_tfwt I bave a certificate of consent to self � 'O� msme I a tertificate f Workers'Compensation Insurynce, COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS or a Rerhfifsd copy ther/of (Sec 3000 Lab C ( ' s' Isal.cy No Company FOR APPLICANT TO FILL IN AE�'L^ 2 If 0 Certified copy is'hereby furnished t New Residential Bldgs 8 Pools EACH NO FEE J EJCertified copy is filed with the county building inspec- 1 & 2-Family,Sq Ft $ — S LOCALITY hon department Multi family Sq F — NEAREST Residential Swimming Pools OWNNEBROSS� Date Applicant FIRM tR CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets Rec—Light_Sw_ MAIL COMPENSATION INSURANCE JADDRESS L [ First 20 This section need not be completed R the work Imobed by Total No Additional CITY Tel the perrttit Is for one hundred dollars ({100)or Ins ) PIAN CHECK ' I certify that in ,he performance of the work for which this APPLICANT J- Lir t permit is issued, I shall not employ any person in any manner L. htin Fixtures First 20 ADDRESS ( nL,� so as to become subject to the Workers Compensation Laws g g ( I, RJ Ft�[c�sy.a,- ow 2-2- 1 t Additional ' Date Applicant Total No CITY Fixed Appliances Not Over 1 HP PERMIT NOTICE TO APPLICANT If after making this Certificate of Exemption, you should become subject to the Workers -Range— Heater—D W _ APPLICATION _ Compensation provisions of the Labor Code you must forth- l Oven _ Dryer —W M — ADDRESS with comply with such provisions or this permit shall be Top — FAU —W H — deemed revoked Hood — Fan —Other_ CITY T 'LZS LICENSED CONTRACTORS DECLARATION LICENSE OR Q� D.sp _ Room Air Canal REG NUMBER O 7� Class I hereby affirm that I am licensed under provisions of Chapter 9 - (commencing with Section 7000)of Division 3 of the Business Power Apparatus 8 Large Appliances DISTRI N ESSED BY d and Professions Code and my license.s in full force and effect c ��,�/� �/�� fy I Size 8 Type HP, KW, KVA or KVAR v U License Number- Class 1/ Up to 1 Incl FINAL / �T _, ,� U S Over 1 to 10 Ind DATE VALIDATION � Contractor Dc to Over 10 to 50 Incl V ❑ FINAL 1 am exempt under Sec Over 50 to 100 Inc BY JQ, W B 8P C for this reason Over 100 0. Services, Swbd , MCC& Ponelboards Z Dote Z t 0-200 Amp Under Epp V Signature 201 - 1000 Amp Under 600 V ❑ Exemption for Reg Maint Elect Over 1000 Amp or Over 600 V,- SINGLE FAMILY Temp Power Pole 8 Appurtenancesl 2 HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit �CT�T I hereby affirm that I am exempt from the Contractor s License Additional Sign Branch Circuits Low for the following reason (Section 7031 5 Business and g M7 25.511 Professions Code) Ell, m owner of the property will do the work and the M sc Conduits 8 Conductors 1 ITEMS structure is not intended or offered for sale(Section 7044 Other (See Complete Fee Schedule)_ ► - - TOTAL 25 . 50 Business and Professions Coda) CONSTRUCTION LENDING AGENCY _ IJECK 25.513 1 hereby affirm that there is a construction lending agency for ,011 the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) (Sec 3097 Civ C ) PLAN CHECKING FEE OOM-0001 11/15/89 Lender's Name PERMITISSUING FEE Lenders Address � - 6812 1 - AM 9:0.? - ' 1 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 hereby authorize representatives of this County to enter upon . _ the above- n d pr party for tinpechon purpos SEE REVERSE FOR EXPLANATORY LANGUAGE S, ature of Perm. is to �s WORKERS COMPENSATION DECLARATION to 79A6e3 10,61 APPLICATION FOR ELECTRICAL PERMIT {1 I flHreby elfirm Plat I hHve a certificate Ycate of cbnsem to self insure °E 8066 �J or a certificate oL"kl ory-6amperlsatlon Insurance or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY copy thereof(�LeIY C) l�(� Palzy Cn1'llpallY FIXi APPLICANT TO FILL M _ JOB ADDRESS l ❑ Cerbl ed copy is ereby furnished New Residential Bldgs & Pods 'EACH NO FEE Certified copy Is filed with the county wilding irmpection 1 & 2-Family Sci Ft S = $ LOCALITY C Multi-family Sq FtNEAREST Residantal Swimming e r �� O ST patg O'NNER OR 11 pl //2�, FPM NAME N ,-v- CE TE F EXEMP INSURANCE WORKERS Outlets Rev.;3 Light 21 Sw� _ '.�� ,:v v AooREss ( section n1 a completed If the work Invotved by the First 20 mit 1 e hundred dokere($100)or lees) Total No Additional CITY I certify that in the performance of the work for which this permit FLAN CHECK �I is awed I shall not empty eery person in APPLICANT any manner so as to ' / become subject to the Workers Cm operlsation Laws Lighting Fixtures First 20 - DO ADDRESS l00 Additional ' Data Applicant Total No�._ /y- CITU - Tel NOTICE TOI APPLICANT If, after making the Certibcate Of Fixed Apdianrces Not Over 1 HP r ` b Exemdon You should become subject to the Workers Compensation Ranpe2 Heater DW J� APRtjG NT ��— prbwsions of the Labor Code you must forthwith comply with such Oven _ Dryer �r W M ADDRESS p"Weis or this Pemut shall be deemed revoked _ Top FAU WH LICENSED CONTRACTORS DECLARATION Head an � Other— CITU Tel N I hereby affirm that I am licensed under provisions of Chapter 9 Dlsp Room Fur Cond — LICENSE OR G� (commencing with Section 7000)of Division 3 of i the Business and , REG NUMBER Professions Codeland Try license is in full force end effectDLSTRICr y D B Paver Apparatus 6 Large Appliances ]v( I �+ g (JT dA yrt Size 8 Type HP,KW KVA,or KVAR Q License Lis Classw' T �O_` UP to 1 Incl FINAL��/ —�/�/ C�7 Over 1 to 10 Ind VALIDATION Q Contract Date Over 10 to 50 Incl lU- ❑ I am exempt under Sec Over 50 to 100 Inc FINAL BY B&PC for thin reason Over 100 r N Data Services Swbd MCC & Panelboards Z o-200 Amp Under Boo V Signature 201 - 1000 Amp Under 600 V Over 1000 Amp or Over 600 V ❑ Exemption for Reg Maim Elect SINGLE FAMILY Temp Power Pole& Appurtenances 2 HOME OWNER-BUILDER DECLARATION Sign vdith One Branch Circuit . r • I Hereby affirm that I ann exempt from the Contractors License Law pC�,T,; V the following reason(Section 7031 5 Business and Professions Additional Sgn Branch Grcuits Code) , 3W 408.00 ❑ I as owner of the property will do the work and the structure I Misc C°rldua1 s&Conductors 1 ITT a not intended or offered for sale (Section 7044 Busmess Other(See Complete Fee Schedule) and Professions Code) ► TOTAL 408.00 CONSTRUCTION LENDING AGENCY -� CkCK _ 408.00 1 hereby affirm that there a a construction lending agency for the performance of the work for which this permit is issued(Sac 3097 PERMIT FEE v (Sub-Total) C .00 Civ C) Lenders Name PLAN CHECKING FEE .. 0000-OIJO1 4/19/90 PERMIT ISSUING FEE LeMera Address - 0186 1 All 8=25 1 certify that I hews mad this appbcaten and state that the above TOTAL FEE Information ire correct I agree to comply with all C my ordinances , and State laws regulating Electncal wing and hereby authorize representatrve�o this Coun ( ro enter upon the above-rtlerltnnad - reaper &Brie our es Q SEE REVERSE FOR EXPLANATORY LANGUAGE to De