HomeMy Public PortalAbout5752 TEMPLE CITY BLVD_Electrical__ WORKER'S COMPENSATION DECLARATION 20-0019 DPW 02-91) n PPn C n TON FOR ELECTRICAL
LECTRIC w L PERMIT
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I hereby affirm that I have a certificate of consent to self Insure,
or a certificate of Worker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS BUILDING AND SAFETY DIV.
copy thereof(Sec.3800 Lab.C.)
policy No. Company FOR APPLICANT TO FILL IN ADDRESS aTL,�q C.41 YI�
EACH FEE
Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. LOCALITY
❑ 1&2-Family,Sq.Ft. — $ $
Certified copy is filed with the county building inspection _ NEAREST
department. Multi-family Sq.Ft. CROSS ST. 2A 110&Z4
Date Applicant Residential Swimming Pools ASSESSOR
APSSOK
PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec. Light Sw. OWNER OR
COMPENSATION INSURANCE FIRM NAME /4/
First 20 MAIL 0
(This section need not be completed if the work Involved by the Total No. Additional ADDRESS . '�� f/�
permit is for one hundred dollars($100)or less.)
I certify that in the performance of the work for which this permit CITY m Tel'
is issued, I shall not employ any person in any manner so as to PLAN CHECK
become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 APPLICANT
Total No. Additional ADDRESS
Date Applicant RESIDENTIAL APPLIANCES NOT OVER 3 HP.
NOTICE TO APPLICANT: If, after making this Certificate of CITY Tel.No.
Exemption,you should become subject to the Workers'Compensation OTHER APPLIANCES NOT OVER 3 HP.
provisions of the Labor Code, you must forthwith comply with such PERMIT �S�D� /tea
p y p y Power Apparatus&Large Appliances APPLICANT 0 A
provisions or this permit shall be deemed revoked.
LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS It 2p&% if ��
I hereby affirm that I am licensed under provisions of Chapter 9 Over 3 to 10 Incl. if
4-4
(commencing with Section 7000)of Division 3 of the Business and CITY t� No.
Professions Code,and my license is in full force and effect. Over 10 to 50 Incl. LICENSE OR
Over 50 t0 100 Ind. REG.NUMBER Clara' a
Over 100 DISTRICT NO. 0— PROCESS O
License Number Lic.Class 0
Services,Swbd.,MCC&Panelboards
L 0
Contractor Date 0-393 Amp.Under 600 V DATE DATE
❑ I am exempt under Sec. 400-1000 Amp.Under 600 V ♦� ( � �Z./ VALIDATION W
Over 1000 Amp.or Over 600 V FINAL
B.&P.C.for this reason BRANCH CIRCUIT FEES BY N
Date: 15A,or 20A,120V,Lighting or Recept. 94.1 Z
1 To 10 Branch Circuits
Signature 11 To 40 Branch Circuits
F-141 Or More Branch Circuits
Exemption for Reg.Maint.Elect. 15A,20A,208V To 277V Lighting Sr.Circuits
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
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits
Code):
1,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 Professions Code).
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) a
Civ.C.)
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE � 7
Lender's Address
I certify that I have read this application and under penalty of purjury state TOTAL FEE
that the 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-mentioned property
for insp ctlon purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
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S'GNATURE F PERMITiE ! ATL -