HomeMy Public PortalAbout6161 1/2 TEMPLE CITY BLVD_Electrical__ �. WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12-91) APPLICATION FOR ELECTRICAL PERMIT
?'hereby affirm that I have a certificate of consent to self Insure,
or a certificate of Worker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS BUILDING AND SAFETY DIV.
copy thereof(Sec.3800 Lab.C.)
Policy No. Company FOR APPLICANT TO FILL IN JOB
ADDRESS
Certified copy is hereby furnshed. New Residential Bldgs.&Pools NO. EACH FEE
$ $ LOCALITY s
❑ Certified copy is filed with the county building Inspection 1 &2-Family,Sq.Ft. NEAREST
department. Multi-family Sq.Ft. CROSS ST.
Date Applicant Residential Swimming Pools ASSESSOR
PAGE PARCEL
WNEROR
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec._Light Sw. FIRM NAME �•
COMPENSATION INSURANCE
First 20 MAIL !
(This section need not be comploted if the work Involved by the Total No. Additional ADDRESS Amb
0 'Are
permit Is for one hundred dollars($100)or less.) , Tol.N* 0,2S>Ly
I certify that in the performance of the work for which this permit CITY m c 174v
Is issued, 1 shall not employ any person in any manner so as to PLAN CHECK
become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 APPLICANT
Total No. Additional ADDRESS
Date Applicant RESIDENTIAL APPLIANCES NOT OVER 3 HP.
NOTICE TO APPLICANT: If, after making this Certificate of CITY Tel.No.
Exemption,you should become subject to the Workers'Compensation OTHER APPLIANCES NOT OVER 3 HP.
provisions of the Labor Code, you must forthwith comply with such APPLICANT
provisions or this permit shall be deemed revoked. Power Apparatus&Large Appliances f
LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS
I hereby affirm that I am licensed under provisions of Chapter 9 Over 3 to 10 Incl.
(commencing with Section 7000)of Division 3 of the Business and CITY Tel.No.
Professions Code,and my license is In full force and effect. Over 10 to 50 Incl. LICENSE OR >-
Over 50 to 100 Incl. REG.NUMBER Clsss. 0.
License Number Lic.Class Over 100 DISTRICT NO. D� PROCESS BY 0
/Services,Sr anelboards
Contractor Date /® Amp.U er 600 V DATE c
❑ !� mp.Under 600 V , 1l-2Y—�� VALIDATION V
I am exempt under Sec. Over 1000 Amp.or Over 600 V FINAL W
B.&P.C.for this reason BY C„ a
BRANCH CIRCUIT FEES
Date. 15A,or 20A,120V,Lighting or Recept.
1 To 10 Branch Circuits
Signature 11 To 40 Branch Circuits
❑ 41 Or More Branch Circuits /A/0
Exemption for Reg.Maint.Elect. 15A,20A,208V To 277V Lighting Br.Circuits
SINGLE FAMILY Temp.Power Pole&Appurtenances x/>15 2
HOME OWNER-BUILDER DECLARATION ��3C a
I hereby affirm that I am exempt from the Contractor's Licensle Law Sign with One Branch Circuit ACCT°a
for the following reason (Section 7031.5, Business and Profesa�ons Additional Sign Branch Circuits 37603 65.60
Code): �`
Misc.Conduits&Conductors �/ I NUB
I,as owner of the property,will do the work and the structure �. „-5�
Is not intended or offered for sale(Section 7044, Business Other(See Complete Fee Schedule) ® TOTAL l.5-_"-c 610.
and Professions Code). 65°60
CONSTRUCTION LENDING AGENCY CPA,1'r,^ °00
I hereby affirm that there is a construction lending agency for the
performance of the work for which this permit is issued(Sec. 3097, PERMIT FEE (Sub-Total)
Civ.C.)
PLAN CHECKING FEE cam—mal 1 12/15/95
Lender's Name
—`
PERMIT ISSUING FEE � 3797 1 ��I
?-1 °
Lender's Address
I certify that I have read this application and under penalty of puqury state TOTAL FEE tG
that the 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-mentioned property
for inspection purposes. ' SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE OF PERMITTEE DATE