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Home My Public Portal About6042-6044 TEMPLE CITY BLVD_Electrical__ WORKERS'COMPENSATION DECLAR03ION 174 3 10401 ,APPLICATION FOR ELECTRICAL PERMIT I hereby affirm that I have a certificate of consent to self CE-806G �� insure, or a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES. /rte d, BUILDING AND SAFETY r or a certifiedcopythereof(Sec. 3800 Lab. C Compan S -to ' a� FOR APPLICANT TO FILL IN JOB I_AX _ ❑ Certified co is hereby furnished. EACH NO. FEE ADDRESS PY Y New Residential Bldgs. Pools LOCALITY L Certified copy is filed with t e ount building inspec- C1 &2-Family, Sq. Ft�=== $ — $ ti de rtment. `Multi-family Sq. Ft. o �"� V — .2 NEAREST rX' Residential.Swimming Pools CROSS ST. a Date V Applica OWNER OR FIRM NAME RTIFICATE OF EXEMPTION FROM WORK RS' Outlets: Re.- Light Sw._ 11M IL COMPENSATION INSURANCE ADDRESS �� y 20 (This section need not be completed If the work involved'by '7 0 First ti Total No. Additional CITY Tel. No. the.permit is for one hundred dollars($1100)-or less.) PLAN CHECK I certify that in the performance of the work for which this PLANCHET 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 Total No. 1 Additional CITY Tel. No. Date Applicant Fixed Appliances\Air 1 HP PERMIT NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT Exemption, you should become subject to the Workers' Range— Hea .W: Compensation provisions of the Labor Code, you-must forth- Oven —Drye .M.. ADDRES with comply with such provisions or this permit shall be Top FA U .H. — deemed revoked. CITY Tel o. . R 1 ' LICENSED CONTRACTORS DECLARATION Hood F<Fanther_ Disp. Roond. LICENSE O �1 Q Gf Class. I hereby affirm that I am licensed under provisions of Chapter 9 REG.NUMBER J o l .(commencing with Section 7000)of Division 3 of the BusinessDISTRICT NO. PROCES D BY and Professions Code,and my license is in full force and effect. Power Apparatus&Large Appliances �j Size&Type HP, KW, KVA, or KVAR• c 0 O License Number`ll;lkCl q Lic. ass(es Up to 1 Incl: FINAL `Q A.0 � � 4?�- Over 1 to 10 Incl. DATE yr VALIDATION' Contract ��' $ n ��teOver 10 to 50 Incl. FINAL U ❑ I am exem t under$ec. Over 50 to.]AO Inc. BY In B.&P.C. forthis reason Over 100pU) Services,Swbd., MCC&Ponelboards D es 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 hereby affirm that I am.exempt from the Contractor's License Additional Sign Branch Circuits r r Law for the following reason (Section 7031.5, Business and Professions Cod.ej: ❑ I,.as owner of the property, will do the work and the Misc. Conduits&Conductors r. o. o o. a ; 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) c �d G �` (. /t —F (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 Ay uthorizerepresentatives of this County to enter upon - entioned property for ins actionurposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature cVf Per 'i tee to WORKERS'COMPENSATION cafe of cons CE-I76A663 10Y81 APPLICATION FOR ELECTRICAL PERMIT . I hereby affirm that I .have a certificate of consent to self CE-806G insure, or a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY or a certified copy thereof(Sec. 38 Lab. C. �.n J try .y PJ .1 4 Company l'IS . d- ' JOB FOR APPLICANT TO FILL IN ADDRESS '�X17 �L., Mink, ❑ Certified copy is hereby furnished. New Residential Bldgs. &Pools EACH NO. FEE 1 &2-Family, 5 Ft.. $ _ $ LOCALITY Certified copy is filed with .e count wilding inspec- � Y• q• 'NEAREST t' n de rttment. ulti-family Sq. Ft. ��tlf Date` y App lica Residential Swimming Pools CROSS ST. OWNER OR FIRM NAME e7 C31/� CERTIFICATE OF EXEMPTION FROM WORKE S' Outlets. c Light. Sw._. MAIL COMPENSATION INSURANCE ADDRESS �-, This section need not be completed �j First 20 ( if the work involved b V Total N . ( Additional .CITY Tel. No.01'7�. the permit is for one hundred dollars.(5100)or less.) 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 Fixtures First 20 ADDRESS Total No. 1 Additional CITY Tel. No. Date Applicant Fixed Appliances N Over 1 HP PERMIT NOTICE TO APPLICANT: If, after making this Certificate of r Exemption, you should become subject to the Workers' Range_ Heater D.W. APPLICANT' Compensation provisions of the:Labor Code, you must forth- Oven�f_Dryer W.M.— ADDRESS (� . P with comply with such provisions or this permit shall be Top _ FAU H. — deemed revoked. CITY LICENSED CONTRACTORS DECLARATION Hood Fan Of r_ Disp. � Room Air Cond. LICENSE OR ♦JI Class. fi-- I hereby affirm 4hat I am licensed under provisions of Chapter 9 REG.NUMBER ` _ (commencing with Section 7000)of Division 3 of the Business DISTRICT NO. PROCE ED BY and Professions Code,and m license is in full force and effect. Power-Apparatus 8 Large Appliances y Size&Type HP, KW, KVA, or KVAR' s—,0 v License Number Lie. Class~ 1 .0 UP to 1 Incl. FINAL 0 (Jq[0Over 1 to 10 Incl. DATE VALIDATION Cant CULL ' Over 10 to 50 Incl. FINAL ❑ A. I am eklimpt under Sec. Over 50 to 100 Inc. BY �r „v,�� AM B.&P.C. for this.reason Over 100 Services,Swbd., MCC&Pane�}boards Poo.Date: 0 -200 Amp. Under 600.(V(QO•y�� Signatur 201 -1000 Amp. Under 6 V ❑ N. Over 1000 Amp. or Over 600 V Exemption for Reg. M.aint. Elect. SINGLE FAMILY Temp. Power Pole&Appurtenances HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit I hereby affirm that lam exempt from the Contractor's License '1 Additional Sign Branch Circuits c 0 a o 0 j Law for the'following reason (Section 7031.5, Business and Professions Code): ❑ I, as owner of-the property, will do the work and the Misc. Conduits&Conductors' structure is not intended or offered for sale (Section Other(See Complete Fee Schedule)_ 7044, Business and Professions Code). , r� �' ;_ () �• CONSTRUCTION LENDING AGENCY h (� �;._�,v 1 hereby affirm that there is a construction lending agoncy for the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) (Sec. 3097., Civ.. Ci).. PLAN CHECKING FEE Lender's Name PERMIT ISSUING FEE U 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 ereby authorize representatives of this County to enter upon f e bov entione property for insp ction p rPoses. al SEE REVERSE FOR EXPLANATORY LANGUAGE V Signature of Perm tee Date WORKERS'COMPENSATION ATIQN 76-663 ,1Q/81 h• APPLICATION FOR ELECTRICAL PERMIT hereby affirm that I have a certificatecafe ofof consent to self CE-806G insure,411or a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY or a certified copy thereof(Sec. 3800, Lab. C.) Policy No. JOB Company FOR APPLICANT TO FILL IN ADDRESS - Certified copy is hereby furnished. New Residential Bldgs. &Pools EACH NO. FEE ❑ i &2-Family, S Ft. $ — S' LOCALITT— Certified copy is filed with the county building inspec- y q' 'NEAREST tion department. Multi-family Sq. Ft. Residential Swimming Pools CROSS ST. Date, Applicant OWNER OR FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw._ MAIL COMPENSATION INSURANCE ADDRESS SCI This section need not be completed If the work involved b First 20 the the is for-one hundred dollars($100)or less.) Y Total No. Additional CIT � Tel. No. I certify that in the performance of the work for which this PLANA CHECK permit is issued, I shall not employ any person.in any manner so as to become subject to the Workers'Compensation' L s. Lighting Fixtures First tADDRESS Additional Date 0 Applicant If, Total No. CITY Tel. No. NOTICE TO APPLICANT: f,p ,ant after aking thj Certificate of Fixed Appliances Not Over 1 HP PERMIT _ Exemption, you should become subject to the Workers' Range_ Heater_D.W. APPLICANT Compensation provisions of the Labor Code, you.must forth- Oven _Dryer, _W.M.— ADDRESSC � with comply with such provisions or this permit shall be Top _ FAU —W.H. _ CITY TelNodeemed revoked. Hood _Fan _Other_ ''K t7 — 9 LICENSED CONTRACTORS DECLARATION LICENSE OR a I 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. PROLES ED BY and Professions Code,and my license is in full force and effect. Power Apparatus&Large Appliances ��/ n Size&Type HP, KW, KVA, or KVAR- _ License Number 2 k'f9j t 2 'Lie. Class C^r a-. � Up to 1 Incl. FINAL � Contractor � � `��Datg 2 Over 1 to 10 Incl. DATE _7 V VALIDATION ❑ Over 10 to 50 Incl. FINAL t� I am exempt under Sec. Over 50 to 100 Inc. BY -f d+ B.&'P.C. for this reason Over 100 Date: II Services, Swbd.,MCC&Ponelboards i 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 hereby affirm that I am exempt'from the Contractor's License Additional Sign Branch Circuits Law for the following reason (Section 7031.5., Business and Professions Code):. ❑ I, as owner of the property, will do thework and the Misc.,Conduits&Conductors C. 7 1.6 A structure is not Intended or offered for sale (Section Other(See Complete Fee Schedule)_ , n u o 0 o G 7044, Business and Professions Code).' CONSTRUCTION LENDING AGENCY G;i.,Q I hereby affirm that there is a construction lending agency for r ^ the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) . .0 (Sec. 3097, Civ.. C.). Lender's Name PLAN CHECKING FEE 1 0 07—S%2 - 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 hereby uthorite representatives of this County to enter upon. the a-me tioned pr rty for inspection purposes, SEE REVERSE FOR EXPLANATORY LANGUAGE Si nature o ;Onifttee Date WORKERS'COMPENSATION DECLARATION8 IAMBI APPLICATION FOR ELECTRICAL PERMIT I hereby affirm that I have a certificate of consent to se if insures.of a,cerrttificate 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 Certified copy is hereby furnished. �' New Residential Bldgs. &Pools EACH NO. FEE ADDRESS 0 Certified copy is filed with the county building inspec- 1 &2-Family, Sq. Ft. $ — $ LOCALITY �s tion department. I Multi-family Sq. Ft. — NEAREST Residential Swimming Pools CROSS ST. Date Applicant Residential OR FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' MAIL /' Outlets: Rec Light Sw._ J COMPENSATION INSURANCE ADDRESS This section.need not be completed if the work Involved b First 20 ( P Y CITY Tel. No. the permit Is for one hundred dollars(;100)or less.) Total No. Additional 3/ I certify that in the performance of the work for which this PLAN CHECK permit is issued, I shall not employ any person in any manner APPLICANT so as to become subject to the Workers'Compensation'La Lighting Fixtures First 20 ADDRESS Total No. Additional CITY Tel. No. Date �1 " pplicant AP TO APPLICANT: If, after making thi Certificate of Fixed Appliances.Not Over 1 HP PERMIT Exemption, you should, become subject to the Workers' Range— Heater_D.W. _ APPLICANT Compensation provisions of the Labor Code, you must forth- Oven —Dryer —W.M.— ADDRESS -71 og- �+� with comply with such provisions or this permit shall be Top _ FAU —W.H.. deemed revoked. CITY Tel. IVo. LICENSED CONTRACTORS DECLARATIONLICENSE OR Hood _ Fan _Other_ ?? o I hereby affirm that I am licensed under provisions of Chapter 9 j Disp. _ Room Air Cond. REG.NUMBER Class. �-/Q (commencing with Section 7000) of Division 3 of the Business = Power Apparatus&Large Appliances DISTRICT NO. PROCESSED BY and Professions Code,and my license is in.full force and effect. Size&Type HP, KW, KVA, or KVAR• License Number. � —Lid. Class C Up to 1 Incl. FINAL W 09 Contractor�n. s �QC/1 Date /' Over 1 to..10 Incl. DATE s P, VALIDATION ❑ Over 10 to 50 Incl. AL I am exempt under Sec. Over 50 to 100 Inc. BY a. B.:&P.C. for this reason Over 100 Date: Services,SwbMCC 8 Panelboards ► /�� I_� � . 0 -200 Am p: Under 600 V Signature 201 - 1000 Amp. Under 600 V ❑ . 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 Law for the following reason (Section 7031.5, Business.and 67 •,',! Professions Code): aMlsc. Conduits&Conductors I, as owner of the property, will da the work and the t o o u o o structure is .not intended or offered for sale (Section Other(See Complete Fee Schedule)_ 7044, Business and Professions.Code).. ► j' 0 0 2 J CONSTRUCTION LENDING AGENCY �. 1 hereby affirm that there is a construction lending agency for " "U ro the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) 4l,C I — (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 ordina es and.State laws riligulating Electrical wiring, and hereb auth iie represents es oft 1s County to enter upon the a ve- g ntioned or pe y for in pection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE VLOZI ,V, 0 4A.- `5igr1•tu.re of Per itteel V Date