HomeMy Public PortalAbout6009 TEMPLE CITY BLVD_Electrical__ WORKERS'COMPENSATIONDECLARATION CE66A-8663
APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm #hat I have a certificate of consent to self COUNTY OF LOS ANGELES s BUILDING AND SAFETY
insure,or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec.3800,Lab.C.)
FOR APPLICANT TO FILL IN JOB 10.
^
Policy No. Company EACH NO. FEE ADDRESS (1
New Residential Bldgs.&Pools
Certified copy is hereby furnished. 1 &2-Family,Sq. Ft. $ — $ LOCALITY j
Certified copy is filed with the countybuilding inspection •Multi-family Sq. Ft. — NEAREST
department. Residential Swimming Pools CROSS ST
P OWNER OR
FIRM.NAME
Date Applicant' .Outlets: Rec,_Light - Sw. MAIL
First 20 __ADDRESS
CERTIFICATE OF EXEMPTION FROM.WORKERS' I Total Nb. Additional CITY Tel No.
COMPENSATION INSURANCE }
PLAN CHECK d
(This section need not be completed if the work involved , APPLICANT
V
by the,permLighting Fixtures First 20 it is for one hundred dollars ($100) or less.)• � ADDRESS
Total No. Additional
I certify that in the performance of the work for which this +Fixed Appliances Not Over 1 HP CITY Tel No. O
permit is issued, I shall not employ any person.in any manner PERMIT / U
so as to.become subject to the Wo ars' 'o 'pensation Laws. Range_Heater D.W._ APPLICANT W
l a
Q� Ali Oven _ Dryer_W.M._ ADDRESS
Date d ~A'!"Applicant. 1111441 .VTop —FAU _W.H..— d
CITY Tel No.
Hood _ Fan. _Other— ,
NOTICE TO APPLICANT: If, after making this Certificate of Disp. Room Air Cond.— LICENSE OR ,o�
e.
Exemption, you should become subject. to the Workers' REG.NUMBS Class:
Compensation provisions of the Labor Code., you must forth- 'Power Apparatus&Large Appliances DISTRICT NO. a PROC WSED BY
with comply with such provisions or this permit shall be
deemed revoked. ; Size&Type HP,KW,KVAor KVAR 1 (f
' f � Up to 1 Incl. '
Over 1 to 10 Inc[. DA EL
LICENSED CONTRACTORS DECLARATION Over 10 to 50 Incl. A��� VALIDATION
hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. FINAL. a ,.
9 (commencing with Section 7000)of Division 3 of the Busi- I Over 100 BY
nes.and Professions.Code,'and my license is,in full force and
effect. Services
�al0-200 Amp.Under 600 V
`License Number Lic.Class' 201-1000 Amp.Under 600 V. S� s
Zntractor ate � P13 Over 1000 Amp.or Over 600 V '
e
HOME OWNER-BUILDER DECLARATION Temp.Power Pole&Appurtenances
I hereby affirm that I am exempt from the. Contractor's Sign with One Branch Circuit
License-Law for the following reason (Section 7031,.5, Busi-
,Additional Sign Branch Circuits
ness anti Professions Code):
Misc.Conduits&Conductors
I, as owner of the property, will do the work and the Other(See Complete Fee Schedule)— ;21 811.9 A
structure is not intended or offered for sale.(Section ,
7044,Business and Professions Code). ? # 0 0 0' o a Z
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency 2 0 - 19.5O
for the performance of the work for which this permit is
issued(Sec.3097,Civ.C.). 'PERMIT FEE (Sub-Total) l–,)— 0 I "0 0 o 1 9.5 0 z
U
Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee) - I
' 7 oa22-s-o
Lender's Address PERMIT ISSUING FEE '
I .certify that I have read this application and state that the TOTAL FEE �Q i
above information is correct.I agree to comilly with all County
ordinances and Stat laws regulating Electrical wiring, and i
hereby aut ize r tat'ves,of this County to enter upon I i,
the atiov n pr p' for ins ction purposes. SEE'REVERSE FOR EXPLANATORY LANGUAGE
gnature of Permittee Date