HomeMy Public PortalAbout6131 TEMPLE CITY BLVD_Electrical__ WORKERS'COMPENSATION DECLARATION CE-806 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,or /
a certified copy thereof.(Sec,3800,,L .C.).
�.I�0. ! FOR APPLICANTTO FILL-IN jpg
0 6 Compan EACH NO. FEE ADDRESS
New Residential Bldgs.&Pools
1 Certified copy is hereby rnishe ", 1 &2.-Family,Sq. Ft. $ _ $ LOCALITY p
Multi-family Sq. Ft. — NEAREST
Certified.copy is filed with t .co ty building inspection CROSS ST
depa tmen . Residential Swimming Pools OWNER OR c
FIRM NAME c7�+
Datel Applican jOutlets, Rec.—Light Sw. ADDRES :
First 20
CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. Additional CIT Tel No.
COMPENSATION INSURANCE
PLA C a
APPLICANT
(This section need not be completed if the work involved OCA
Lighting Fixtures First 20
by the permit. is for one hundred .dollars ($i00.) or less.) �, - ADDRESS ,
Total No. Additional cc
I certify that in the performance of the work for which this CITY Tel No. (D
permit is issued, I shall not empl'o any person in any manner Fixed Appliances Not Over 1 HP
PERMIT
so as to become subject to the o k rs'Compensation Laws. Range_Heater D.W. APPLICAN
+ Oven _ Dryer_W.M.:_ ADDRES y
Date Applica; Top _ FAU _W.H.•_ 2
Hood _ Fan _Other_ CITY Tel No
OTICE TO APPLICANT: if, after making this Certificate of Disp. —Room Air Cond— LICENSE OR
xemption, you should become subject to .the Workers' I- REG.NUMBE922—SX-1—class
ompensation provisions of the Labor Code,you must forth 'Power Apparatus&Large Appliances - DISTRICT NO. PROCES ED BY
Hfth comply with such provisions or this permit shall be ,
deemed revoked. Size&Type HP,KW,KVA,or KVAR
'Up to 1 Incl. �sd�
Over 1 to 10 Incl. FINALDATE
LICENSED CONTRACTORS DECLARATION `rI .� p VALIDATION.
Over 10 to 50 Incl. O
I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100Inc. FINAL r
9 (commencing with Section 7000)of Division $ of the Busi- Over 100 BY
ness and Professions.Code, and'my license is in full force and
effect. , Services nG ��
7 / 0-200 Amp.Under 600 V �(f T
License Num Lic.Class 201-1000 Amp.Under 600 V
Co >irac or Date ��L Over 1000 Amp.or Over 600 V
O E -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
Ell, as owner of the property, will do the work and the Other(See Complete Fee Schedule)— 1 2 5 1'A
structure is not intended or offered for sale (Section
7644,Business and Professions Code).
CONSTRUCTION LENDING AGENCY a ( o 0 0 0 0
I hereby affirm that .there is a construction,lending agency
for the performance of the work for- which this permit is 2'o 0 1 4,50
issued(Sec.3097,Civ.C.).
PERMIT FEE (Sub-Total)
Lender's Name PLAN CHECKING FEE (.One-Fourth Permit Fee)
01301th5005
Lender's Address PERMIT ISSUING FEE 1.05-82
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. th ze representatives of this County to enter upon
the o entioned property for inspection purpose SEE'REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee I ate
WORKERS'COMPENSATIONDECLARATION ICE-sorG (2.80) APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self J COUNTY OF LOS ANGELES _ BUILDING AND SAFETY
insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof.(Sec.30,La .)
FOR APPLICANT TO FILL IN JOB
Policy No.i_ Comps80EACH NO. F.EE ADDRESS
- New Residential Bldgs.&Pools
❑ Certifiecopy is hereby furnished. 1 &2-Family,Sq. Ft: $ — $ LOCALITY
®
Multi-family Sq. Ft. NEAREST.Certified copy is filed with the county building inspection CROSS ST
department. Resideniial.Swimming Pools OWNER OR
FIRM NAME
Date,,�Applic Outlets: Rec.—Light—Sw. MAIL
First 20 ADDRESS
CERTIFICATE OF E MPTION FROM WORKERS' Total No. . Additional CITY Tel No.
COMPENSATION INSURANCE >wPLAN CHECK C-
(Tl"tis section need'not be completed if the work involved APPLICANT 0
by the permit is for one hundred dollars,($100) or less.) Lighting Fixtures First 20 ADDRESS
Total No. I Additional O
I certiFixed
fy that in'the performance of the work for which this Appliances Not Over 1 HP CITY Tel.N.o. 0
permit is issued,'I shall not employ any person in any manner PERMIT W
so as to become subject to the Workers'Compensation Laws. Range_Heater D.W._ APPLICANT a
Oven _ Dryer_W.M._ ADDRESS N
Date Applicant Top _ FA _W,H.._ CI �
Hood _ Fan _Other_
001,
NOTICE TO APPLICANT: If, after making this Certificate.of Disp. —Room Air Cond— , LICENSE OR
Exemption, you should become subject to the Workers' – REG.NUMB 4V� Class
Compensation provisions of.the Labor Code,you must forth- Power Apparatus&Large Appliances D'ISTRICT:NO. PROCES D B�
with comply with such provisions or this permit shall be Size&Type HP,KW,KVA,or kVAR �^ �y�,
deemed revoked. Up to 1 Incl. J V
LICENSED CONTRACTORS DECLARATION Over 1 to 10 Incl. DATEL
Over 10 to 50 Incl. �-1 VALIDATION
I hereby affirm that I•am licensed under provisions of Chapter Over 50 to 100 Inc. FINAL `
9 (commencing witti'Section 7000).of Division 3 of the Basi- Over 700 BY
ness and Professions.Code, and my license is in full force and Z
effect. Services
Licehs Numb Lio.Class cl0-200 Amp.Under 600 V
�j 201-1 000Amp.Under 600 V
Co r Dated Over 1000 Amp,or Over 600 V
�� Jr J
HOME OWNER-BUILDER DECLARATION i Temp.Power Pole&Appurtenances
I hereby affirm that I am exempt from the Contractor's Sign with One Branch Circuit 2 2'1 4 !�
License Law for the following reason (Section 7031.5, Busi- Additional Sign Branch Circuits
ness and Professions Code):, V 0 0 0.o o 2
Misc.Conduits.&Conductors
ElI, as owner of the property, will do the work and the I Other(See Complete Fee Schedule)—
i o'0 2 J J O
structure is not intended or offered for sale (Section
7044,Business and Professions Code). - 0 0 0 2 3• G C;3
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency I 1 2 Q 3--i?
for the performance of the work for which this permit is PERMIT FEE (Sub-Total)
issued(Sec.3097,Civ.C.). ' _
Lender's Name PLAN CHECKING FEE (Orie-Fourth Permit Fee)
Lender's Address PERMIT ISSUING FEE
_$ 0
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 above-men ' property for inspection purposes'.
GG � SEE'REVERSE FOR EXPLANATORY LANGUAGE
Signature of Yermittee Date `
B�BBs-CE90B 10.82 APPLICATIO FOR ELECTIZICAL PERMIT
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER F
ING /
BUILDING AND SAFETY DIVISION ESS � T
JOHN A. LAMBIE, COUNTY ENGINEER
WILLIAM A.JENSEN,SUPT OF BUILDING LITY �/
EST
OR APPLICANT TO FILL IN S ST.
RECEPr. TOTAL NO. EACH FEE
OU� FIRST ZO �:Eo $ ER / �/ �/
LIGHT
ADD'L J� ESS
SWITCH. OVER 2O .fO (,/
TOTAL TEL.No.
LIGHTING FIRST 2O .20
FIXTURES � ADD'L
OVER20 .10 TRICIAN
RANGES CLO.DRYE S WTR.HTRS. 1.00 ADDRESS
GARB.DISP. STA.COOK
CITY TEL.NO.
DISH WASH. /1 wuro..wASH STATE '1
SPACE HTRS. STA.APP.(V$H.P.MAX.) .50 LICENSE NO. dr/
MOTORS: OVER NOT OVER H.P. DIS�T!A/C�T O. GROUP ONE ESSED Y
O 1 1.00 ✓ tf J.
1 S 1.50 INSPECTION RECORD
s .s 2.00 It
a 1s 2.50 O
U
1s so 3.00
so too 5.00
SIGNS: NO.TRANS.
NO.LAMPS - N
SERVICE 0-000V-Nor OVER 200A 1.00 z
SERVICE 0-600V-OVER 200 A. 2.00
SERVICE OVER 600V 5.00
MISC.
PERMIT ISSUING FEE 2.00
SUPPLEMENTARY PERMIT ISSUING FEE 1.00
TOTAL FEE
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATI N APPROVALS DATE INSPECT R'8 SIGNATURE
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CONDUIT
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
ELECTRICAL WIRING. WIRING
1 HEREBY C'RjJIW THAT I AM PROPERLY REGISTERED AND/OR
LICENSED AS R U ED BY LOS AN7�EZ�HTY AND STATE OF FIXTURESCALIFORNIA O TH T 1 AM THELROF'THE ABOVE
DESCRIBED RES E IA ROPERTY. POWER _
SIGNATURE UTILITY CO.NOTIFIED I Ae. w
OF PERM; yf-
FINAL
^LIDATION ARTHUR C. VEIT J
ay/ MO CASH SUPERVISING ELECTRICAL ENGINEER