HomeMy Public PortalAbout6211 TEMPLE CITY BLVD_Electrical__ WORKERS'COMPENSATION DECLARATION 78-883 10/91 APPLICATION FOR ELECTRICAL PERMIT J�
1 hereby-affirm that'I'have a certificate of consent to self insure, CE-808G `I
or a certificate of Workers' Compensation insurance,or a certified COUNTY OF LOS.ANGELES BUILDING AND SAFETY 'uI
copy thereof(Sec. BAQ+L84. //O
Poli No.A/-C Company � S FOR APPLICANT TO FILL IN JOB / n -
14
Certified copy'is.hereby furnished. New Residential Bldgs.&Pools
EACH NO. FEE ADDRESS ao[
_ LOCALITY
❑'• Certified copy is filed with the county buil in inspection 1 &2-Family,Sq.Ft.-ate $• ' 5 NEAREST
depar 'en Multi-family Sq.Ft.
CROSS ST.
Date+ Applicant Residential.Swimming Pools OWNER OR
FIRM NAME {I
CERTIFICATE OF EXEM ON FROM WORKERS' Outlets:Rec—Light_Sw.— +' MAIL 45dt d- e wl w e
COMPENSATION INSURANCE First 20 ADDRESS ,
(This section need not be completed if the work Involved by the Total No. Additional CITY saN Ijf' Tel.No� 01
permit Is for one hundred dollars($100)or less.)
PLAN CHECK
I'certify that in the performance of the work.for which this permit APPLICANT
is issued, I shall not employ shy 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 PERMIT
NOTICE TO APPLICANT: If_ after making this ,Certificate of APPLICANT f/ V C
Exerpption,you should become subject to the Workers'Compensation Range_ Heater_ D.W.. _ �/
,provisions of the Labor Code,you.must forthwith comply with such. Oven _ Dryer= W.M._ ADDRESS 'BI.����
provisions or this permit shall be deemed revoked. Top _ FAU• ._ W.H.
CITY S M . . Tel.No
LICENSED CONTRACTORS'DECLARATION -Hood — Fan _ Other_ ,.
,I hereby-affirm that.I am licensed under,provisions of Chapter 9 Dis . — Room Air Cond.
LICENSE OR Class.
(commencing with Section 7000)of Division 3 of the Business and p REG..NUMBER ��d
Professions Code,and my license is in full force and effect. DISTRICi No. ESSED BY
• Power Apparatus&Large Appliances d
/� Size&Type HP,KW,KVA,or KVAR � O
License Number Lic.Classy�� Up.to,1 Incl. FINAL
Over.1 to 10 Incl. DAA `�^�-� VALIDATION p
Contractor Date. Over 1.0 to 50 Incl. U
FINAL '
❑ I am exempt under Sec. ' Over 50 to 100 Inc. + BY UJ
B&P.C.for this reason Over 100 M
N
Services,Swbd.,MCC&Panelboards ® Z
Date: 0-200 Amp.Under 600 V
Sibnature 201 - 1000 Amp.Under 600 V
Over 1000.Amp,or Over 600 V
ElExemption for Reg.'Maint.Elect.
JL
SINGLE FAMILY Temp..Power Pole&AppurtenancesCT n
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License Law IAdditional Sign Branch Circuits ? 248.95
for the following reason(Section 703:1.5,Business and Professions •.
Code): , 1 ITM
AAisc,Conduits&Conductors '
El 1, 248.95
I,as owner of the property,will do the work and the structure Other'(See Complete Fee Schedule)
is not intended or offered'for sale (Section 7044, Business •
and Professions Code). ► O.RK
2481.95
CONSTRUCTION LENDING AGENCY CHNGE .00
I hereby affirm that there is a construction lending agony for the n
performance of the work.for which this permit is issued'(Sec.3097, PERMIT FEE (Sub-Total) pr�.i
Civ.C.). (MOO-0001_ 8/ 8/95
PLAN CHECKING-FEE
Lenderls.Name 3G .1726 1 IAM 8002
• � PERMIT ISSUING FEE,
Lender's Address
I certify that I have read this,application and state that the above TOTAL FEE 7
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 ins p do purp es. SEE REVERSE FOR EXPLANATORY LANGUAGE
epi Date