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Home My Public Portal About6209 TEMPLE CITY BLVD_Electrical__ S • I I WORKER'S COMPENSATION DECLARATION +20001.9 DPW(12-91) APPLI.CATI N.F: R ELECTRICAL PERMIT ' `76A663 I Hereby affirm that I have a certificate of consent to self Insure, `I Or a certificate of Worker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT,OF PUPLIC WORKS BUILDING AND SAFETY DIV. copy thereof(Sec.-3800 Lab.C.) Po cY Nd. I6 COm anLFOR APPLICANT TO FILL IN JOB - • P Y --•1 ADDRESS Z �,�, ✓� Certified copy Is hereby furnished. New Residential Bldgs.&Pools NO. E 4GH, FEE LOCALITY _ $ Certified copy is filed with the county building inspection 1 &2-Family,Sq.Ft. $' NEAREST .department. MUlti-family Sq.Ft. CROSS ST. Date ��'fes Applicant Residential Swimming Pools ASSESSOR BOOK AAE PARGEL04a�� D CERTIFICATE OF EXEM FROM ORKERS' Outlets:Rea._Light Sw. r OWNEROR FIRM NAME COMPENSATIONINSURANCE First z;.,-20 (This section.need not be completed If the work Involved by the . ADDRESS�� yd 9 permit Is for one hundred dollars($100)or less.) Total No. Additional I certify that in the performance of the work for which this permit ; CITY Tel.No. 1 Is issued, I 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.ko. 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 suchPPPMIT1 Lo provisions or this permit shall be deemed revoked. Power Apparatus.&Large Appliances LICENSED CONTRACTORS DECLARATION Size&Type. KW,KYA,or KVAR ADDRESS J?� _ J �C 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.Nos 3 Professions Code,.and my license is in full force and effect. 'Over 10 to 50 Incl. LICENSE oR } Over 50 to 100 Incl. zaaCl REG.NUMBER ass' d Over 100 DISTRICT NO. .PROCESS Y O t✓License Number S �� Lic.Class. () Services,Swbd.,MCC&Panelboards Contractor f Y/' late f�� 0-398 Amp.Under 600 V DATE• _ 400-1000 Amp.Under 600 V - VALIDATION. W I Orn,exempt under Sec.. Over 1000 Amp.or Over 600 V FINAL O. -B.&P.C.for this reason BRANCH CIRCUIT FEES BY (n Date: 15A,or 20A,120V,Lighting or Recept. Z_ 1 To 10 Branch Circuits Signature 11 To 40 Branch Circuits ❑ 4.1 Or More BranchCircuits ., 3 Exemption for Reg.Maint.Elect. 15A,20A 208V To 277V Lighting Br.Circuits ;;303 SINGLE FAMILY Temp.Power Pole&Appurtenances ER-COR HOME OWNER-BUILDER DECLARATION it cu Sign with One Branch Cir -• - I hereby.affirm that I am exempt from.the Contractor's License Law 3303 A for the following reason.(Section 7031.5, Business and Professions Additional Sign Branch Circuits Code): .4 Q 1,as owner of the property,-will do the work and the structure Misc.Conduits&Conductors ' Vii.•:f:a� is not intended or offered for sale(Section 7044, Business Other(See Complete Fee Schedule) { VCand Professions Code). 330-3 Ot.r'tr•J CONSTRUCTION LENDING AGENCY L FTE!'I��+ I hereby-affirm that there Is a.construction lending agency for the T 8. 8 performance of the work for which this permit is issued Sec. 3097, PERMIT FEE i . p ( (Sub-Total) �'. CHECK 68.8`J ' Civ.C:) PLAN CHECKING FEEa 70 Lender's Nam PERMIT PERMIT ISSUING FEE Lender+s Address TOTAL FEE I certify that'I have read this application and under penalty of purjury state Z, O g000—000 l 5/15/95 that the above information is correct. I agree to comply with all County 0396 ordinances and State laws regulating Electrical wiring,and hereby authorize f representatives of this County to enter upon the above-mentioned property for inspection p s. SEE REVERSE FOR EXPLANATORY LANGUAGE SIGNATURE•OF . ITVE DATE ;WORKERS"COMPENSATION DECLARATION 78ABej 10181 EE-BOBG APPL�CATIO'I�J .FORI.:ECTRICA.L PERMIT {� 'I.�her$by affgri.that.I Ai'Ave a'certificate of,consent to .self Insure, LI or a certificate of Workers'Compensation Insurance, or a certified COUNTY'OF LOS ANGELES BUILDING AND SAFETY copy. thereof(Sec.3800,Lab..1C.) V A ,� '•pr Poli. Nolwe?A Vmpany L rA&rw �V�• FOR APPLICANT TO FILL IN JOB . ADDRESS' Certified'copy:is hereby furnished. New Residential Bidgs.&Pools EACH NO. FEE 1 &2-Family,.Sq.Ft — ❑ Certified .copy is filed'with 'the county ilii' I :pe n, $ $ a .. . de tme Multi=family Sq.Ft.. —.1 NEAREST LOCALITY ._ . CR SSS. Date. 5 Applicant. Residential Swimming Podls OWNER OR 'FIRM.NAME X7 !7 PITIFICATE OF EXEMP N'FR 'WORKERS' -• Outlets:Reo—Light—Sw.= ;" i i MAIL � r. COMPENSATION INSURANCE ADDRESS a. , �. ��. First.;20 (This section need-not be completed If.the work.involved by the' CITY Tel. Total.No. Additional permit is for one hundred dollars($10(})or.less.,) " ,PLAN CHECK • 1 certify'that in the performance.of the.work.for which this permit APPLICANT is issued,I shall not employ apy person in any manner.so as.to become subject to the Workers'•Compensation Laws. Lighting Fixtures First 20 ADDRESS Additional Total No. CITY Tel.No. Date Applicant Fixed Appliances Not Over 1 HP NO,TI.CE TO .APPLICANT: If; :after making this.,Certificate.'Of PERMr! Eicemption,.you should become:subject to the.Workers'.Compensation. Range._ Heater D.W::'_ APPLICANT provisions of the Labor Code,you must forthwith comply with such- Oven — Dryer_--_ -W.Mi ADDRESS provisions:or this;permit:shall'be deemed revoked. Top _. FAU _ W.H. _ CITY' Tel.No. LICENSED.CONTRACTORS,DECLARATION Hood - Fan _ O.ther_ � 5 I hereby.affirm that.Ham,licensed under•provisions of Chapter 9 LICENSE OR Disp. — Room Air Cond: REG NUIv18E Class. (commencing,with.Section 71j00)of Division.3.of the Business:and • - -.- • -� R 3 � • .3 �o :Professions.Code,and my license,is Wfull force and effect. DISTRICT NO. ES$E.t,BY Power Apparatus&;Large Appllonces //��] Size&Type HP,KW,K_VA,or.KVAR• �J �� j License Number �`P.7 2 �+ Lic,(Class (f—/.0 ' L 1 Q,. Up to 1 Incl. FINAL f Over 1.to 10 Incl. DATE.• VALIDATION Q Contractor��1 �� / Date S Over 10 to FINAL `5.O Incl. L �. I AT exempt:under Sec.. - ... :� Over 50•to 100 Inc. d Over=100' BAP.C.fcX this reason. N Services,Swbd.,MCC&Panelboards ® ' Date:. 0-200 Amp.-Under 600 V Signature 201•-1000 Amp.Under 600 V' Over 1000 Amp.or Over 600 V. ❑ Exemption for,Rep.'Maint.Elect. SINGLE.FAMILY Temp.Power Pole&Appurtenances 2 HOME OWNER-BUILDER DECLARATIONa ' ' 'I hereby affirm that I am exempt from the Contractor's Licehse Law. Sign with One Branch Circuit; 04 for.the following reason(Section 7031.5,Business and Professions Additional Sign Branch Circuits. • 51x37 Code): , 1,as owner of the property,will do the w6rk and the.structure. Misc.Conduits&Conductors •ITG ,; , is not intended'or offered for sale (Section 7044, Business '.'Other(See Complete Fee Schedule) �r TOTAL .25.1.37 and'Frofessions Code). - GK 21037' -CONSTRUCTION LENDING AGENCY I hereby affirm:that there is a construction lending agency for the CHANGE 000 .performance.of the.work-'for which this.permit is issued(Sec.3097, PERMIT FEE. (Sub Total) 191Q 07 PLAN.CHECKING FEE M06—ml 8/ 8/95 Lender's Name. ' PERMIT ISSUING FEE 1725' 1 V $0-02 Lender's Address �, I certify that I have read this application and state,that the above 'TOTAL FEE , 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 props o ctl Dees: p- SEE REVERSE-FOR EXPLANATORY.LANGUAGE Signa o ee Date - .. "