HomeMy Public PortalAbout6012 TEMPLE CITY BLVD_Electrical__ y, WORKERS''.604PENSATION DECLARATION 76A663 `
• CE-806G (2-80) APPLICATION FOR ELECTRICAL PERMIT
E hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY
insure,or a certificate of Workers'Compensation Insurance,or ,
a certified copy thereof(Sec.3800,Lab.C.)
Policy No. Company FOR APPLICANT TO FILL IN JOB
ADDRESS I� -C
New Residential Bldgs.&Pools EACH NO. FEE Q
Certified copy is hereby furnished. 1,,&2-Family,Sq.Ft. �_ $ — $ LOCALITY �–
❑ Multi-family Sq. Ft..o7 _ — NEAREST (]
Certified copy is filed with the county building inspection CROSS ST I":.C
department. Residential Swimming Pools OWNER OR
' FIRM NAME
Date Applicant' Outlets: Rec.—Light—
Sw. MAIL4. 1
First 20
CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. Additional CIT Tel No.
COMPENSATION INSURANCE
PLAN CHEC d
APPLICANT O
(This section need not be completed if the work involved U
by the permit is for one hundred dollars ($100) or less.) Lighting Fixtures First 20 ADDRESS
Total No. Additional O
I certify that in the performance of the work for which this CITY Tel No.
Fixed Appliances Not Over 1 HP
permit is issued, I shall not employ any pers n in any manner , PERMIT / t .. W
.so as .to become subject to the Worker •C pe ion Range_Heater D.W.._ , APPLICANT _ p a
Oenca
_ Dryer_W.M._ ADDRESS Bax 79, Z
Datery Applican op _FAU _W.H..
Hood•_ Fan. —Other— CITY Tel'No.
NOTICE TO APPLICANT: If, after ing this Certificate of Disp. _Room Air Cond.— LICENSE OR c�7
Exemption, you should become subject to the Workers' REG.NUMBER, Class
Compensation provisions,of,the Labor Code, you must forth- Power Apparatus&Urge Appliances ' DISTRICT NO. P E S BY
with.comply with such provisions or this permit shall be R I' h {
deemed revoked. Size&Type HP,KW,KVA,or KVAI � V g
Up to 1 Incl. ;
'Over 1 to 10 Incl. FIINALDATE . ;
LICENSED CONTRACTORS DECLARATION Over 10 to 50 Incl. l�'"� VALI'D'ATION
I hereby affirm that.I am licensed under provisions of Chapter Over 50 to 100 Inc. FINAL
By
9 (commencing with Section 7000)of Division 3 of the Busi- Over 100
ness and•Professions.Code,and my'license is in full force and
effect. Services
0-200 Amp.Under 600 V
License Number - Lie.Class 201-1.000 Amp..Under 600 V
Contractor Data Over 1000 Amp.or Over 600 V
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 and Professions Code):
' ' Misc.Conduits&Conductors t
I, as owner of the property, will do the work and the Other(See Complete Fee Schedule)— q
structure is not intended or offered for sale (Section { �; ?V .
•7044,Business and Professions Code). l
'CONSTRUCTION LENDING AGENCY J
I hereby affirm that thereis a construction lending agency
for the performance: of the work for which this permit is y +B`J
PERMIT FEE (Sub-Total)
issued(Sec.3097,Civ.C.).
Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee)
Lender's Address PERMIT ISSUING FEE {�• 'D` o"•)
I certify that I have read this application and state that the TOTAL FEE 0'7
above information is correct.I agree to comply with all County I e
ordinances and State. laws r ting Electrical wiring, and
hereby author, rep ntativ of my to enter upon
the abov on roperty o SEE'REVERSE FOR EXPLANATORY LANGUAGE
Ila
Signet ur Pe ee Date ;