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Home My Public Portal About6023 TEMPLE CITY BLVD_Electrical__ V�{ORKERS'COMPENSATION DECLARATION 76A663 10181 APPLICATION FOR ELECTRICAL PERMIT �i;'her-%V-affirm that I have a certificate of consent to self CE-8066 insure, or a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY or a certified copy thereof(Sec. 3800, Lab. C.) Policy No. Company FOR APPLICANT TO FILL IN JOB l� Certified copy is hereby furnished. EACH NO. FEE ADDRESS 4/_1200S New Residential Bldgs. 8 Pools — LOCALITY `�,�'�� "9Certified copy is filed county building mspec- 1 &2-Family, Sq. Ft. $ $ �e- —tion department. �j t Multi-family Sq. Ft. — NEAREST _ L� CROSS ST �+�+��L Date ��- Y Applic Residential Swimming Pools OWNER OR rl FIRM NAME C_s CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec. Light Sw.COMPENSATION INSURANCE ADLRSS - (�� First 20 JiL C/d! (This section need not be completed If the work Involved by Total No. Additional CITY��!t�✓�� Tel. No. the permit Is for one hundred dollars($100)or loss.) that in the performance of the work for which this PLAN CHECK I certify P APPLICANT permit is issued, I shall not employ any person in any manner " (' so as to become subject to the Workers'Compensation Laws. Lighting Fixture First 20 ADDRESS Total No. 6 Additional CITY Tel. No. Date Applicant Fixed Appliances Not Over 1 HP PERMIT ,�� _F� NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT CCli e,&7;6� C Exemption, you should become subject to the Workers' Range_ Heater_D.W. Compensation provisions of the Labor Code, you must forth- Oven _Dryer W� W.M. W- ADDRESSC/-024C) 4,45'—FC with comply with such provisions or this permit shall be Top _ FAU —W.H. — deemed revoked. Hood Fan _Other_ CITY 6''� Tel. NoZa2-S-ZQs- � — LICENSED CONTRACTORS DECLARATION i c : ,j LICENSE OR I hereby affirm that I am licensed under provisions of Chapter 9 Disp. ` Room Air Cond. REG. NUMBER Class.G�® (commencing with Section 7000)of Division 3 of the Business DISTRICT NO PR C SED BY Power Apparatus&Large Appliances ;- } and Professions Cade,and my license is in full force and effect. c y- Size&Type HP, KW, KVA, or KVAR -�' - / % e. License Number��? L:c. ClassUp to 1 Incl. G `y FINAL Contre�t� �/-7 ' y Over 1 to 10 Incl. DATE ` /Zlf VALIDATIO Ote � Over 10 to 50 Incl. [, FINAL � ❑ I am exempt under Sec. Over 50 to 100 Inc. BY B.&P.0 for this reason Over 100 Date: Services, Swbd., MCC&Panelboards 0 -200 Amp. Under 600 V Signature 201 - 1000 Amp. Under 600 V = ! v 2 t , ❑ , Exemption for Reg. Mainf. Elect. Over 1000 Amp. or Over 600 V (� o a o c SINGLE FAMILY Temp. Power Pole&Appurtenances o O /, ') HOME OWNER-BUILDER DECLARATION' Sign with One Branch Circuit I hereby affirm that I am exempt from the Contractor's License Additional Sign Branch Circuits o ' Law for the following reason (Section 7031.5, Business and Professions Code): c, r ❑ Misc. Conduits&Conductors ( 1'C 7 j, as owner of the property, will do the work and the structure is not intended or offered for sale (Section Other(See Complete Fee Schedule)_ 7044, Business 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 PERMIT FEE (Sub-Total) (Sec. 3097, Civ. C.). PLAN CHECKING FEE Lender's Name PERMIT ISSUING FEE Lender's Address ,• I certify that I have read this application and state that the TOTAL FEE above information is correct. I agree to comply with all County ordinances and State laws regulating Electrical wiring, and y authorize representatives of this County to enter upon 6e eeve-me tion pro inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of P mrttee Date WQRKERS'COMPENSATIONDECLARATION CE-806G (2.80) APPLICATION FOR ELECTRICAL PERMIT ' CE-806 Y hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELESr�� 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 p� Policy No. Company. EACH NO. FEE ADDRESS New Residential Bldgs.&•Pools F1 Certified copy is hereby furnished. 1 &2-Family,Sq. Ft. $ — $ LOCALITY !q OMulti-family Sq. Ft. NEAREST Yi Certified copy is filed with the county building inspection CROSS ST 4 department. Residential SwimKiing Pools OWNER OR FIRM NAME !� Date Applicant Outlets: Rec.�ight Sw. 5� MAIL First 20 ADDRESS CERTIFICATE OF EXEMPTION FROM WORKERS' Total No.—yC� Additional CITY el No. �; _1t 6 COMPENSATION INSURANCE } PLAN CHECK d ' APPLICANT O (This section need not be completed if thework involvedLighting Fixtures I First 20 V by the permit is for one hundred dollars ($100) or less.) ADDRESS - Total No. Additional O I certify that in the performance of the work for which thisFixed Applt Over 1 HP CITY Tel NQ_ iances No permit is issued, I shall not employ any person in any manner � PERMIT W W as to become subject to th Workers' ompensation Laws. Range_Heater D.W. _ APPLICANT IL s Oven _ Dryer_W.M._ ADDRESS CO Date�" �" Applicant �,a ,449 —FAU-_W.H.._ Hood _ Fan _Other_ CITY Tel No. NOTICE TO APPLICANT: If, after making this Certi cate of Disp. _Room Air Cond._ LICENSE OR Exemption, you should become subject to the Workers' REG.NUMBER Class Compensation provisions of the Labor Code,you must forth- Power Apparatus&Large Appliances DISTRICT NO. PROCESSED BY with comply with such provisions or this permit shall be - deemed revoked. Siie&Type HP,KW,KVAor KVAR g • Up to 1 Incl.. L a ' Over 1 to 10 Incl. . FINAL DATE VALIDATION LICENSED CONTRACTORS DECLARATION Over 10 to 50 Incl. - I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. FINAL BYc- 6 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 License Number 0-200 Amp.Under 600 V Lic.Class 201-1000 Amp.Under 600 V Contractor Date 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): • 0.21., A Misc.Conduits&Conductors •, fr 0 0 0 0 0 2 I, as owner of the property, will do the work and the Other(See Complete Fee Schedule)— structure is not intended or offered for sale (Section 2 0 - 16.00 ' 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY o 0 0 1 L'-,6 C.-J I hereby affirm that there is a construction•lending agency for the performance of the work for which .this permit is PERMIT FEE (Sub-Total) 07,06-81. issued(Sec.3097,Civ.C.). Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee) Lender's Address PERMIT ISSUING FEE I certify that I have read this application and state that the TOTAL FEE above 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 Bove- a oned property for inspecti purposes. SEE-REVERSE FOR EXPLANATORY LANGUAGE 0`tiupC o Signature of Permittee Date WORKERS'COMPENSATIONDECLARATION! CE-806G (2-80) APPLICATION FOR ELECTRICAL PERMIT I 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,on, a certified copy thereof(Sec.3800,Lab.C.) I y Policy No. Company i FOR APPLICANT TO FILL I JOB ADDRESS ® • New Residential Bldgs.&Pools EACH NO. FEE / ✓ • 0 Certified copy is hereby furnished. 1 &2-Family,Sq. Ft. $ — $ i LOCALITY y'_ �� ` � Multi-family Sq. Ft. NEAREST 54 Certified copy is filed with the county building inspection Residential Swimming Pools CROSS ST /fes department. OWNER OR • pq FIRM NAME" Date ® � pplican& a RT7i Outlets: Rec.-Light Sw. MAI L First 20 ADDRESS CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. Additional CIT Tel No. COMPENSATION INSURANCE l " }a PLAN HE APPLICANT. (This section need not be completed if the work involved IU by the permit is for one hundred dollars ($100) or iless.) Lighting Fixtures First 20 ADDRESS Total No. Additional O I certify that in the performance of the work for which this Fixed Appliances Not Over 1 HP CITY Tel No. � permit is issued, I shall-not employ any person in any mannerPERMTT W so as to becoine subject to the Workers'Compensation Laws. Range_Heater D.W. APPLICAN A7® . p, Oven — Dryer_W.M._ ADDRESS to Z Date Applicant Top _ FAU _W.H. 4&6 hro&e- , o Hood — Fan —Other CITY 6, • NOTICE TO APPLICANT: If,after making this Certificate of Disp. _Room Air Condom LICENSE OR Exemption, you should become subject to the Workers' REG.NUMBER Class '140 Compensation provisions of the Labor Code,you must forth- Power Apparatus&Large Appliances DISTRICT NO. P BY with comply with such provisions or this permit shall be deemed revoked. Size&Type HP,KW,KVA,or KVAR � Up to 1 Incl. FINAL'S v Over 1 to 10 Incl. DATE LICENSED CONTRACTORS DECLARATIONOver 10 to 50 Incl. � �s � VALI DATION I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. FINAL 9 (commencing with Section 7000)of Division 3 of the Busi- Over 100 BYa lf" � ness and Professions.Code, and my license is in full force and effect. Services License Number LIC.Class-C— & 0-200 Amp.Under 600 V Him ra 201-1000 Amp.Under 600 V Contractor Date � ®"i�� Over 1000 Amp.or Over 600'V HOME OWNER-BUILDER DECLARATION Temp.Power Pole&Appurtenances I hereby affirm that I am exembt 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): I Misc.Conduits&Conductdrs ❑ I, as owner of the property, will do the work and the Other(See Complete Fee Schedule)— structure is not intended or offered for sale (Section 1 2 C ";, 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY - �,' u o n e o I hereby affirm that there is a construction lending agency for the performance of the work for which'this permit is PERMIT FEE (Sub-Total) C ° L l issued(Sec.3097,Civ.C.). Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee) a Lender's Address PERMIT ISSUING FEE ( n 1 2- 80 I certify that I have read this application and state that the TOTAL FEE above information is correct.I agree to comply with all County ordinances and State laws regulating -Electrical wiring, and i hereby authorize representatives of this County to enter upon the above-ment' red property for inspection purposes. I SEE'REVERSE FOR EXPLANATORY LANGUAGE fto i na of Pe tt Date