HomeMy Public PortalAbout6215 TEMPLE CITY BLVD_Electrical__ WORKERS'COMPENSATION DECLARATION 78-683 10/81 APPLICATION .FOR ELECTRICAL PER
I hefebV affirm•thAt i'have a certificate of consent to self insure, GE-906G ;
or a certificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
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copy.thereof. c.3800,Lab.C.) /Ilffl /�
Poli No. Company • �+ e- ' FOR APPLICANT TO FILL IN JOB I
Certified copy is-hereby furnished. EACH NO. FEE ADDRESS
New Residential Bldgs.&Poolls
Certified copy is filed with the county building inspection 1.&2-Family,Sq.Ft. $ _ $ O + LOCALITY
dep tment. Multi-family Sq.Ft.. — NEAREST
Residential Swimming Pools. CROSS ER O
Date Applicant -FIRM NAME _,JB �7lZyed
CERTIFICATE OF EXEMPTION•FRAr -OM WORKERS'
COMPENSATION INSURANCE Outlets:Rec—Light_Sw,— ADDRESS
(This section need not be completed,if the work Involved by the First 20
permit is for one hundred dollars($100)or less.) Total No. Additional CITY ,�,� �aA&W Tel:.No. ,3
I certify that in.the performance of the work for which this permit PLAN CHECK
is issued, I shall not employ any person in any manner so as to• APPLICANT
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
NOTICE TO APPLICANT: 'If, after making this Certificate of PERMIT FU /NC•
Exeinption,,you should•beeome subject to the Workers'Compensation Range_ Heater_ D.W. ._ APPLICANT
provisions of the Labor Code,you must forthwith comply with such Oven _ Dryer_ W.M._ ADDRESS t. ~
provisions or this permit shall be deemed revoked. Top. — FAU _ W.H. _ CITY' S G Tel.No�
LICENSED.CONTRACTORS DECLARATION Hood — Fan _ Other_
I hereby.affirm that I+am 11censed'under provisions of Chapter,9D'Isp. r Room Air Cond.
LICENSE OR
. REG.NUMBEClas& t7
(commencing with Section 7000)of Division 3 of the Business andRs
Professions Code,and my license is in,full force and effect. Power Apparatus&Large Appliances DISTRICT No. P Q ESSED BY
Q Size&Type IJP,KW,`KVA,or KVAR 4
License Number ,03�/ •Lic.Class Id Up to 1 Inc[, FINAL
Contractor/�/ �� ���• Date V Over 1 to 10 Incl. VALIDATION,- Q ,
Over 10 to 50 Incl. F
FINAL (j
❑, I am exempt under Seo. Over:50 to 100 Inc. BY W
Over 100 0-
B,&P.C.for this reason
Services,'Swbd.,MCC&Panelboards Z
Date: 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 2 '
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit ACCTo v
I hereby affirm that I am exempt'-from.the Contractor's.License.Law
for the following.reason(Section 7031.5,Business and Professions Additional Sign Branch Circuits
Code): 33Q3 '' 24851Misr:Conduits&Conductors 1 ITEMS
• 0 I,as owner of the property,will do the work and the structure •
is not intended or offered for sale.(Section 7044,.Business Other(See Complete Fee Schedule) _ TOTAL 1248 o
and Professions Code). ® 2�8v
CONSTRUCTION LENDING AGENCY t x �E o
I hereby affirm that there is a construction lending agency for the 4
performance of the work for which this permit is Issued(Sec.3097, PERMIT FEE (Sub-Total) 02�
Civ:C.).
PLAN CHECKING FEE
Lender's.Name 0.000-0001 8/ 8/95
PERMIT ISSUING FEE �aZ,.I �
Lender's Address / - 1728 1 AM 8003
TOTAL FEE
1 certify that I have read this application and state that the above A49 .6-1
informatign 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.or' e tion r gees. SEE REVERSE FOR EXPLANATORY.LANGUAGE
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Mir
nat of rmi a Date