HomeMy Public PortalAbout6349 TEMPLE CITY BLVD_Electrical__ WORKERS COMPENSATION DECLARATION 3
CEADOG (2 80) APPLICATION FOR ELECTRICAL PERMIT {�
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I hereby affirm'that I have a certificate of cement to self COUNTY OF LOS ANGEL /J ' BUILDING AND SAFETY
insure or a certificate of Workers'Compensation Insurance,or ('
a certified co r f(Se 3 0,(Lj�b C) / }.—
�� 7�� /n' / z FOR APPLICANT TO FILL IN J(%
P cy of Co pony J N r liLLl New Residential Bldgs &P Js EACH NO FEE ADDRESS wvr
❑ Certified copy is hereby furnished 1 &2 Famdy,Sci Ft �f��9 S — $ 11 LOCALITY
❑ Certified copy B filed with the county buddinginspection Multi family Sq Ft CROSS ST
de art t Residential Swimming Pools OWNEROR
P FIRM NAME
Date r/ Ircant Outlets Rac_LightSw _ MA
�Irst 20 IL
CERTIFICATE OF EXEMPTION FROM ORKERS Total No Additional CITU t4k7 I No
COMPENSATION INSURANCE Y
PLAN CHECK Is.
(Thu section need not be completed if the work involvedAPPLICANT 8
by the permit is for one hundred dollars ($100) or less) Lighting Fixtures First 20 ADDRESS K
Total No Additional 0
pp
1 certify that in the performance of the work for which this Fixed Appliances Not Over 1 HP CITY Tel No F
permit u issued, 1 shall not employ any person in any manner PERMIT U
so as to become subject to the Workers Compensation Laws Range_ Heater_D W _ APPLICANT le,
N
Oven _ Dryer_W M _ ADDRESS Z
Dete Applicant Top _ FAU _W H
Hood _ Fan —Other— CITY Tel No
NOTICE TO APPLICANT If after making this Certificate of Disp _Room Air Cond_ LICENSE R t
Exemption, you should become subject to the Workers JREG NUMBER D Class
Compensation provisions of the Labor Code, you must forth Power Apparatus& Large Appliances DISTRICT NO PPO ED BV
with comply with such provisions or this permit shall be Size&Type HP,KKVA,or KVA f�
deemed revoked W, Q
_ Up toiIncl FINAL
Over 1 to 10 Incl DATE /1
LICENSED CONTRACTORS DECLARATION Over 10 to 501nc1 VALIDATION
I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc FINAL
9 (commencing with Section 7000)of Division 3 of the Bus, Over 100 BY
nese and Professions Code and my license is in full force and q
effect Services �'—"
D ' e 0 200 Amp Under 600 V or ✓ r
License Number, S 2,is Class
201 1000 Amp Under 600 V
Contracto e' ��� T —r{_ d Over 1000 Amp or Over 600 V SS a D
HOME OWNE BUILDER DECLARATION Temp Power Pole&Appurtenances �!3 0 5 1 A
I hereby affirm that 1 em exempt from the Contractors Sign with One Branch Circuit
Additional Sign Branch Circuits # z
License Law for the following reason (Section 7031 S Bust
ness and Professions Code) 2 • • 4 8 9 7
Misc Conduits&Conductors -
❑ 1, as owner of the property will do the work and the Other (See Complete Fee Schedule)— • • • 48 97
structure ac not intended or offered for sale (Section
7044, Business and Professions Cade)
CONSTRUCTION LENDING AGENCY 1 1 13-80
1 hereby affirm that there is a construction lending agency
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 (One-Fourth Permit Fee)
Lender's Address PERMIT ISSUING FEE
I certify that I have read this application and state that the TOTAL FEE
above information is correct 1 agree to comply with all County
ordinances and State laws regulating Electrical wiring, and
hereby authorize representatives of this County to enter upon
men toned property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
M, 13. its
Signature of Pef ittee Date