HomeMy Public PortalAbout5749 TEMPLE CITY BLVD_Electrical__ WORKERS'COMPENSATION DECLARATION 7BA663
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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