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HomeMy Public PortalAbout5749 TEMPLE CITY BLVD_Electrical__ WORKERS'COMPENSATION DECLARATION 7BA663 io/ai CE-808APPLICATION FOR ELECTRICAL PERMIT I hereby!affi M u.�.�'rm that I have a certificate of consent to self insure, i or a certificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELESI BUILDING AND SAFETY copy thereof(Sec.3800.Lab.C.) Policy No. Company I FOR APPLICANT TO FILL IN i JOB Certified co is hereby furnished: i EACH NO. FEE / PY Y i New Residential Bldgs.&Pools $ Y _ $ i. LOCALIT 1 & 2-Family,Sq.Ft. _ r Certified copy is filed with the county building inspection NEAREST department. Multi-family Sq.Ft. CROSS ST. Y�C7 Date Applicant j Residential Swimming Pools OWNER OR �J FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rei: Light V Sw.— MAILCOMPENSATION INSURANCE 3 ADDRESS (This section need not be completed if the work involved by the First 20 CITY r---� T - _ permit is for one hundred dollars($100)or less.)' l I 7 Total No.� Add'ina PLAN CHECK certify that in the performance of the work for which this permit APPLICANT is issued, I shall not employ any person in any manner so as to Jj 2 become subject to the Workers'Compensation Laws. Lighting Fixtures First120 ADDRESS Addiftonal Total No. CITY Tel.No. Date Applicant I Fixed Appliances Not Over 1 HP PERMIT NOTICE TO APPLICANT: If, after making this Certificate of Exemption,,you should become subject to the Workers'Compensation Range_ Heater_ D.W. APPLICANT provisions of the Labor Code,you must forthwith comply with such A4&n Dryer_ W.M._ ; ADDRESS provisions or this permit shall be deemed revoked. Top. _ FAU _ W.H. LICENSED CONTRACTORS DECLARATION Hood — Fan OtherCITY Tel.No. _ I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. rp UCENSE OR Clasa. (commencing with Section 7000)of Division 3 of the Business and REG.NUMBER Professions Code,and my license is in full force and effect. power Apparatus&Large Appliances DISTRICT NO. PRO SSED BY i Size&Type HP,KW,KVA,or KVAR d C License Number Lid.Class Up to 1 Incl. FINAL V Over 1 to 10.Incl. DATE W Contractor Dae — VALIDATION ❑ tOver 10 to 50 Incl. FINAL I am exempt under Sec. Over 50 to 100 Inc. gY LtJ B.&P.C.for this reason' Over 100 +' N' Date: Services,S,I�j�.,MCC&Panelboards ® Z 0 fr24 '�n0 p.Under 600 V Signature ' 201 -­=0 Amp.Under 600 V ❑ Exemption•for Reg.Maint.Elect. Over 1000 Amp.or Over 600 V SINGLE FAMILY Temp.Power Pole&Appurtenances HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit I hereby affirm that I am exempt from the Contractor's License Law - r for the following reason(Section 7031.5,Business and Professions Additional Sign Branch Circuits r.:. : +-- Code): I,as owner of the property,will do the work and the structure Misc.Conduits&Conductors is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) and Professioris Code). I ► i},_ =2 '9P3 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(Sec.3097, PERMIT FEE (Sub Total) Civ.C.). ,! PLAN CHECKING FEE Lender's Name d A c I i' -i-=Ii_ ! Ny y� PERMIT ISSUING FEE -'= _I Lender's Address OAJ _ – - PP TOTAL FEE �J. I certify that I have read this application and state that the above P 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-mentioned propertyfor ins cti ses. SEE REVERSE FOR EXPLANATORY LANGUAGE Ignature o Permitt Date