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HomeMy Public PortalAbout5821 TEMPLE CITY BLVD_Electrical__ 4 WORKERS'COMPENSATION DECLARATION 76A663 10/81 {j . �hereby affirm that I have a certificate of consent to self insure, CE-806G APPLICATION FOR ELECTRICAL PERMIT LJ or a certifii-ate of Workers'Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY copy thereof(Sec.3600,Lab.C.) Policy No. Company FOR APPLICANT TO FILL IN JOB ❑ � Certified copy is hereby furnished. New Residential Bldgs.&Pools EACH NO. FEE ADDRESS S&al 7:jM E1!p $ $ LOCALITY F1 Certified copy is filed with the county building inspection 1 &2-Family,Sq.Ft. _ department. Multi-family Sq.Ft. CROSS ST. L�gNEAREST 1.1 N A- Date Applicant Residential Swimming Pools OWNER OR FIRM NAME L.Gt►tQQ CERTIFICATE OF EXEMPTION FROM WORKERS' AMAIL DDRESS L COMPENSATION INSURANCE Outlets:Rec—Light—Sw.— r (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 CITYZA4 1) Tel. o8'/ L PLAN I certify that in the performance of the work for which this permit APPLICANT CHECK 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 Additional CITY Tel.No. Total No. Date �- Applicant Fixed Appliances Not Over 1 HP PERMIT NOTICE tO A PLICANT: If, after making this (Certificate of APPLICANT -Q___ Exemption,you should become subject to the Workers'Compensation Range_ Heater_ D.W. _ 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. CITY Tel.No. LICENSED CONTRACTORS DECLARATION Hood — Fan _ Other_ I hereby affirm that I am licensed under provisions of Chapter 9LICENSE OR 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. �� PROCESSED BAY iL Size&Type HP,KW,KVA,or KVAR License Number Lic.Class Up to 1 Incl. FINAL /// Over 1 to 10 Incl. DATE ��^! Contractor Date VALIDATION O ❑ Over 10 to 50 Incl. FINAL U I am exempt under Sec. Over 50 to 100 Inc. gY W B.&P.C.for this reason Over 100 L) Services,Swbd.,MCC&Panelboards Date: 0-200 Amp.Under 600 V M' Signature 201 - 1000 Amp.Under 600 V ❑ Exemption for Reg.Maint.Elect. Over 1000 Amp.or Over 600 V at-C 0 5 8 A ' ° ° ° ° ° 2 SINGLE FAMILY Temp.Power Pole&Appurtenances HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit ° ° 2 15 0 1 hereby affirm that I am exempt from the Contractor's License Law Additional Sign Branch Circuits ° ° 2 7 Q for the following reason(Section 7031.5,Business and Professions �" 5 Code): Misc.Conduits&Conductors 0 6,5 0-•S 8 ® I,as owner of the property,will do the.work and the structure is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) _ Poo. 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) Civ.C.). PLAN CHECKING FEE Lender's Name PERMIT ISSUING FEE U Lender's Address I certify that I have read this application and state that the above TOTAL FEE elS J 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 propert for�inspecfi urposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ka,,,,� d gnature oa Date WORKERS'COMPENSATION DECLARATION - 10/81 APPUCATION FOR ELECTRICAL. PERMIT I hereby,a}iir'Iff that Y have a certificate C of consent to self insure, CE-806G �r a certificate of Workers' C"ompensadon Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY dopy thereof(Sec.3800,Lab.G.) - / (Policy No.1)31RVI 9DCompany FOR APPLICANT TO FILL IN JOB DDRESS 2.1 PLE'li 1S n LVO ❑ Certified copy is hereby furnished. New Residential Bldgs.&Pools EACH NO. FEE ❑ $ _ $ LOCALITY ��rti,pl.6 G ve Certified copy is filed with the county Ing inspection 1 & 2-Family,Sq.Ft. department. Multi-family Sq.Ft. — NEAREST L�S rd CROSS ST. NIt S Date �_,__Q©_Applicant Residential Swimming Pools OWNER OR f� rr-� QQ FIRM NAME P"Aal e•fG cgNS 7 ww 7od CERTIFICATE OF EXEMPTION F OM WORKERS' Outlets:Rec L?Light�Sw.1L MAIL COMPENSATION INSU -NCE ADDRESS ��-sZ- LOGIw_-4Zd3R RB. First 20 �v /"' A? t9� g (This section need not be completed if the work involved by the Total No. Additional CITY EL dNre Tel.No.2,87_749 permit is for one hundred dollars($100)or less.) I certify that in the performance of the work for which this permit APP ICANT CHECK is issued, I shall not employ any person in a manner so as to become subject to the Workers'Compe sation a Lighting Fixtures First 20 ADDRESS � 1 �RGr IG C_",ridLTfdtf Total No. Additional CITY Tel.No. Date 0—/—99 Applicant NOTICE TO APPLICANT: If, after akfng this Certificate of Fixed Appliances Not Over 1 HP PERMIT Exemption,you should become subject t the Workers'Compensation Range_ Heater_ D.W. APPLICANT PA��r,� oVS, vLT�d.J 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. _ CITY Tel.No. LICENSED CONTRACTORS DECLARATION Hood — Fan _ Other- 1 hereby affirm that I am licensed under provisions of Chapter 9DiRAiCdLICENSE OR sp. — oom ron . (commencing with Section 7000)of Division 3 of the Business and REG.NUMBER Class. Professions Code,and my license is in full force and effect. Power Apparatus&Large Appliances DISTRICT NO. PROCESSED BY Size&Type HP,KW,KVA,or KVAR License Number 434,4 Lic.Class $C—�D Up to 1 Incl. FINAL 8 Over 1 to 10 Incl. DATE Z� "' VALIDATION � Contractor powpe <B/1L179/lLTr*bate �' ? '9 O Over 10 to 50 Incl. ❑ FINAL I am exempt under Sec. Over 50 to 100 Inc. BY W B.&P.C..for this reason Over 100 9L Services,Swbd.,MCC&Panelboards N Date: 0-200 Amp.Under 600 V Signature 201 - 1000 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 1 for the following reason(Section 7031.5,Business and Professions Code): .l_.�a va Misc.Conduits&Conductors _ ❑ I,as owner of the property,will do the work and the structure 3�1i is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) and Professions Code). j i f I 1r_ - CONSTRUCTION LENDING AGENCY TOTAL ��o so 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) f2w i_ Civ:C.). _ PLAN CHECKING FEE (4(�jti{E Lender's Name PERMIT ISSUING FEE Lender's Address -� I certify that I have read this application and state that the above TOTAL FEE �. �O f}0101 -1„GIS 1 `y' -°f`rl i information is correct.I agree to comply with all County ordinances o We and State laws regulating Electrical wiring, and hereby authorize i' represe tatives o his County to enter upon the a�?o ntioned prope for insp cti purposes. L�_� _ SEE REVERSE FOR EXPLANATORY LANGUAGE "" Signet re of Permittee Date _ _