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HomeMy Public PortalAbout6029-6031 TEMPLE CITY BLVD_Electrical__ eq WORKERS'COMPENSATION DECLARATION CE-806 10/81 APPLICATION FOR ELECTRICAL PERMIT I hereby affirm that I have a je�t'ficotr�,of consent to self CE-806G insure, or a certificate of�IVorkers Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY or a certified copy thereof e3�Sy 3800, Lob. ) Policy N� -ZT Company Z�Zj FOR APPLICANT TO FILL IN' JOB ❑ Certified copy is hereby furnished. f New Residential Bldgs. & Pools EACH NO. FEE ADDRESS Certified Y. q•copy is filed with the county building inspec- 1 &2-Family, S Ft. $ — $ LOCALITY NEAREST Ae tion.department. Multi-family Sq. Ft. CROSS ST. �- .�e .�, N Residential.Swimming Pools OWNER OR 44 Ll Date Applicant FIRM NAME e-- CERTIFICATE CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec 'MAfL L COMPENSATION INSURANCE Light5w._ ADDRESS 0 � 5 1� This section need not be completed If the work Involved First 20 ( p b y Total No. Additional CITY •CK I Tel. No. the permit is for one hundred dollars($100)or less.) PLAN CHECK I certify that in the performance of the work for which this APPLIC,%NT permit 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 TAdditional Total No. CITY Tel: No. Date Applicant Fixed Appliances Not Over 1. HP PERMIT NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT Exemption, you should become subject to the Workers' Range_ Heater—D.W. Compensation provisions of the Labor Code, you must forth- Oven —Dryer —W.M.— ADDRESS with comply with such provisions or this permit shall be Top _ FAU —W.H. — deemed revoked. Hood _ Fan —Other_ CITY Tel. IVoZ LICENSED CONTRACTORS DECLARATION LICENSE OR 1 hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room'Air Cond. REG.NUMBER Class. (commencing with Section 7000) of Division 3.of the Business DISTRICT NO. PROCES BY and Professions Code,and my license is in full force and effect. Power Apparatus,8 Large Appliances Size&Type HP, KW, KVA, or KVAR Ao 0 License Number Lic. Class Up to 1 Incl. FINAL v Over 1 to 10 Incl.. DATE ��Z� VALIDATION Contractor_�—,T $!2Z DateOver 10.to 50 Incl. FINAL ❑ I am exempt under Sec. Over 50 to 100 Inc. BY ®" B.&P.C. for this reason Over 100 PA Date: Services, Swbd., MCC&Panelboards ► Z 0 -200 Amp. Under 600 V Signature 201 -1000 Amp. Under 600 V r ❑ Exemption for Reg. Maint. Elect. Over 1000 Amp. or Over 600 V 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 Additional Sign Branch Circuits r Law for the following reason (Section 7031.5, Business and Professions Code): 0 0 0 , ❑ I, as owner of the property, will do the work and the M:sc. Conduits&Conductors •, � 'r, = +- i• structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ 704.4, Business and Professions Code). r 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 0 Lender's Address ! I certify that I have read this application and state that the TOTAL FEE rJ above information is correct. I.agree to comply with all County ordinances.and State.laws regulating Electrical wiring, and hereby authorize rep sen ives of this County to enter upon thea entione pr rty for inspection:purposes. SEE REVERSE FOR'EXPLANATORY LANGUAGE iril�rl— nature o ermittee Date WORKERS'COMPENSATION DECLARATION CE-806 ,D,BI APPLICATION FOR ELECTRICAL PERMIT I hereby affirm that I have a,certificate of consent to self SCE-806G insure, or a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELESBUILDING AND SAFETY or a certified copy thereof(Sec. 3800, Lab.,C.) Policy No. Company FOR APPLICANT TO FILL IN . JOB T Certified copy is hereby furnished. New Residential Bldgs. &Pools EACH NO: FEE ADDRESS © /"+_ ❑ Certified copy is filed with the county building inspec- 1 &2-Family, Sq. Ft.� ��� $ _ $ LOCALITY� ��� v 71/ tion department. Multi-family Sq. Ft. NEAREST Residential Swimming Pools CROSS ST. Date Applicant OWNER OR FIRM NAME/�V r!� W 1 CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw._ MAIL COMPENSATION INSURANCE ADDRESS %_42 7d571910_1 This section need not be com leted if the work Involved b First 20 ( P y Total No. Additional CITY T Tel. NbMw the permit is for one hundred dollars($100)or less.) I certify that in the performance of the work for which this h APLICCANT permit is issued, I shall not employ any persorw any manner so as to be ome ubject to the Wor rs' ensat' Laws. Lighting Fixtures First 20 ADDRESS y Total No. Additional CITY Tel. No. Date pplicanf Fixed Appliances Not Over 1 HP PERMIT r/ NOTI TO . PPLICANT: If, after making Certificate of APPLICANT 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.M.— ADDRESS L(J Y with comply with such provisions or this permit shall be Top —.FAU —W.H. — deemed revoked. Hood —Fan _Other— CITYS2 �/, , Tel. LICENSED CONTRACTORS DECLARATION LICENSE OR I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. REG:NUMBER (commencing,with Section 7000) of Division 3 of the Business DISTRICT NO. PROCE ED BY Power Apparatus 8 Large Appliances IL �- and Professions Code,.and my license is in full force and effect: L� 0 ,Q' � �j Size&Type HP, KW,•KVA, or KVAR• �l 11 License Number / . Lic.Class Up to 1 Incl. FINAL Over 1 to 10 Incl. DATE f VALIDATION Over 10 to 50 Incl. FINAL ❑ I am exempt under Sec. Over 50 to 100 Inc. BY � am B.'&P.C. for this reason Over 100 Date: Services,Swbd..,MCC&Panel.boords, ► e 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 herebyaffirm that I am.exempt from the,Confractor's License Additional Sign Branch Circuits Law for the following reason (Section 7031.5, Business and 1 5 4,O_A Professions Code): ❑ Misc. Conduits&Conductors -0.0 o a o 2 s as owner o the property, will do the work and the Other See Complete Fee Schedule ► o o Q structure is not intended or offered for sale (Section ( p )— 2 90.50 0 7044, Business and Professions Code). 0 0,a ?Q.Jr L' CONSTRUCTION LENDING AGENCY I hereby affirm that there is a.construction lending agency for F r G the:performance of the work for which this permit is issued PERMIT FEE (Sub-.Total) •V (Sec. 3097, Civ. C.). PLAN CHECKING FEE Lender's Name PERMIT ISSUING FEE 46v 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 ' r ordinances and State laws.regulating Electrical wiring, and hereby ouch WIze representative of this County to enter upon thov - enfio pert r inspect io purpos S. I SEE REVERSE FOR EXPLANATORY LANGUAGE i N � Signa ure a'te