HomeMy Public PortalAbout5753 TEMPLE CITY BLVD_Electrical__ Wo�KERS'hive
a caSATate.of Consent to 78-883 70/91 APPLICATION FOR ELECTRICAL PERMIT
•., K .A CE-808G
^,l,I hervby ir&ti: i I have a certificate.of consent to self insure,
jor a certificate ofLWeekers'Compensation lasurance,br a certified COUNTY OF LOS ANGELES .BUILDING AND SAFETY
copy thereof(Sec.3800,Lab.C.) v.
Policy No. Company FOR APPLICANT TO FILL IN JOB
❑ Certified copy is hereby furnished. EACH NO. FEE ADDRESS S 5 3 �:(. TE,*/=4C C a- (. ,
New Residential Bldgs.&Pools
❑ — LOCALITY
Certified copy is filed with the county building inspection 1 &2-Family,Sq.Ft $ — $ < <
NEAREST
department. Multi-family Sq.Ft. CROSS ST. GV (J J2 /¢ft..,
Date Applicant Residential Swimming Pools OWNER OR
c Light
FIRM,NAME EA n9/¢W a i9 Pn1A•£L
Outlets:ReCj
CERTIFICATE OF EXEMPTION FROM WORKERS' s-- Sw. MAIL
COMPENSATION INSURANCE 5 ® ADDRESS S ? S7) Xf•, ?t� c CC[ BC.
(This section need not be .completed If the work Involved by the First 20
permit is for one hundred dollars($100)or less.). Total No. Additional CITY TGA Tel.No.�g�-,3d<
I certify that in the.performance.of the work for.which this permit PLAN CHECK
APPLICANT
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 ADDRESS
c
Total No.. (e Additional CITY Tel.
Applicant pplicant/0 44aiw- f Fixed Appliances Not Over 1 HP
NOTICE TO APPLICANT: If, after making this Certificate 'of-/ PERMIT
Exemption,you should become subject to the Workers'Compensation Ranr Range_ Heater D.W. — APPLICANT �,cl
provisions 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 _ W.H.
LICENSED CONTRACTORS DECLARATION ' Hood _ ran _ .Other_ CIT Tel:No.
I.hereby affirm that I am licensed under provisions of Chapter 9 LICENSE OF
Disp. — Room Air Cond. ` REG.NUMBER Class.
(commencing with Section 7000)of Division 3 of the Business and -
Professions Code,and my license is in.full force and effect: Power Apparatus&Large Appliances DISTRICT NO. PROC ED BY
Size&Type HP;KW,KVA,or KVAR.. 0
License Number . Lic.Class Up to 1 Incl. FINAL V
Over 1 to 10 Incl. DATE J -0:O
Contractor Date �• Over 10 to 50 Incl. FINAL❑' I am exempt under Sec. Over 50 to 100 Inc. BY LL1
B.&P.C.for this reason Over 100 l N1
Services,Swbd.,MCC&Panelboards
Date 0-200 Amp.Under 600 V
Signature- 201 - 10.00 Amp.Under 600 V
❑ Over 1000 Amp.or Over 600 V
Exemption for Reg.Maint.Elect.
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 Additional Sign Branch Circuits
for the following reason(Section 7031,5,Business and Professions
'Code):
ir
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) 6 8 �,9 A
and Professions Code).CONSTRUCTION LENDING AGENCY .0 0 0 0 0 2
reby affirm that there is a construction lending agency for the
formande of the work for which this permit is.issued(Sec.3087, PERMIT FEE (SubTotal) 'I 0 0 3a00
PLAN CHECKING FEE o 01- 3Q005
Lender's Name ''
PERMIT ISSUING FEE. Ff o 4 0 7 z 8 7
Lender's Address.
1 certify that I have read this application.and.state that the.above TOTAL FEE
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 inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date ,