HomeMy Public PortalAbout5951 TEMPLE CITY BLVD_Electrical__ WORKE,R'S COMPENSATION DECLARATION 204019 DPW 9/89 I 'lull
hereby affirm that I have a certificate of consent to self Insure, 7eM63 APPLICATION FOR ELECTRICAL PERMIT
or a certificate of Worker's Compensation Insurance, or a certifiers COUNTY OF LOS ANGELES DEPT.OF PUBLIP WORKS BUILDING.AND.SAFETY DIV.
copthereof(Stec.3800 Lab.C.) L I i
Policy No.a7,3 7 Company �"/Gt 16e Aws"–dk FOR APPLICANT TO FILL IN JOB r
❑ r`T i ADDRESS S
Certified copy is hereby furnished. I EACH NO. FEE 01
New Residential Bldgs.&Pools $ _ $ I LOCALITY
❑ Certified copy is filed With the county building inspection 1&2-Family,Sq.Ft.
�iepartmen Multi-family Sq.Ft. — NEAR
OSS9 +
(� u
Date Applicant Residential Swimming.Pools �:., y 5. ASSESSOR
i MAP BOOK PAGE PARCEL
CERTIFICATE OF EXEMPTIVNR��IVI'WORKERS' + gj OWNER OR
Outlets:Rec. Light Sw. FIRM NAME
COMPENSATION IANCE G
(This section need not be completed if the work Involved by the First 20 MAIL r ,
permit is for one hundred dollars($100)or less.) Total No. ZQ Additional ADDRESS p . fj
I certify that in the performance of the work for which this permit CITY Tel.No.
.is Issued, I shall not employ any person in any manner so as t'O
become subject to the Workers'Compensation Laws. „ .Lighting Fixtures First 20 ALPAPNL�CCANErCK
Q, � -O O
Total No. Additional kA
ADDRESS
Date Applicant .4
NOTICE TO APPLICANT: If, after making this Certificate o`.f 15 OR 20A,120V BRANCHI CIRCUITS CITY G J.� Tel.No.
'Exemption,.you should become subject-to the Workers'Compensation 1 TO 10 INCLUSIVE EACH
provisions of the Labor Code,.you must forthwith comply with such 11 TO 40 INCLUSIVE EACH PERMIT
el
APPLICANT
provisions or this.permit shall be deemed revoked. 41 OR MORE BRANCH CIRCUITS EACH
LICENSED CONTRACTORS DECLARATION ADDRESS '
I hereby affirm,that I am licensed,under provisions of Chapter,l'g 15 OR 20A,208V TO 277V LIGHTING EACH O
(commencing with Section 7000)of Division 3 of the Business and CITY Tel.No. V
Professions Code,and my-license is in full force and effect. RESIDENTIAL APPLIANCES UP TO 3HP LICENSE OR
Power Apparatus&Large Appliances REG.NUMBER Dliss•
License.Number Lie.Class. 13-1 Size&Type HP,KW,KVA,or WAR l DISTRICT NO. POC SSED BY 0
Up to3Incl. ��O W
Over'1.to 10 Incl.
Contractor ' C�=S�H.�C,! .zk�pate ! 3 DAT co
Over 1.0 to.50.Incl. ��f��� Z
❑ I am exempt under Sec. 'i Over 50 to 100 Incl. / VALIDATION
NAL.100 FI
B.&P.C.for�this reason Over FI °wry/
Services;.Swbd.,MCC&Panelboards
ate' 0 200 Amp.Under 600 V
Signature A4
I 201-1000 Amp.Under 600 V
Over 1000 Amp.or Over 600 V
❑ Exemption.for Re Int.Elect.
SINGLE FAMILY Temp.Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch ClrcUit
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 Clrcuits
Code):
I,as owner of the property,will do the work end the.structu
El 1, Misc.Conduits&Conductors
is not Intended or offered for sale(Section 7044, Business Other(See Complete Fee Schedule) , r'
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)
Civ.C.) 7 Ali,?;q':
PLAN CHECKING FEE .14
Lender's Name ri1`S I'.(=4=
PERMIT ISSUING FEE i RAI `!
Lender's Address TOTAL FEE
1 certify that I have read this application and state that the above TOae 3
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 l
propeit r insp ,len purposes. 4 SEE REVERSE FOR,EXPLANATORY LANGUAGE
^_
SIG REO APPLICANT OR AG - q '