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Home My Public Portal About6351 TEMPLE CITY BLVD_Electrical__ WORKERS'COMPENSATIONDECLARATtON CE-806G 12 BO) APPLICATION FOR ELECTRICAL PERMIT CE-806G / I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES e r BUILDING AND SAFETY insure or a certificate of Workers'Compensation Insurance or �/� e cpL{t[ed Copy er ofg00,Le ) :i� �/ tL(t `(fj� /{Ov FOR APPLICANT TO FILL IN A Po cy o any New Residential Bldgs &Pools EACH NO FEE ADDRESS l Certified copy is hereby furnished 1 &2 Famdy,Sq Fti�?99 $ — S LOCALITY Multifamily Sq Ft T Certified copy u filed with the county building inspection Residential Swimming Poole CROSS ST ...`� depart n OWNER OR �+ FIRM NAME ! V Date s VApphcant Outlets Rec_Light SW MAIL --Fnst 20 ADDRESS Sr (/ CERTIFICATE OF EXEMPTION FROM ORKERS' Total No Additional CITY el No COMPENSATION INSURANCE >- PLA CH CK /IL APPLICANT Fixtures iC (This section need not be completed If,the work Involved Lightixtures First 20 ADDRESS U by the perms[ is for one hundred dollars (S I00)or less) Additional Total No I certify that in the performance of the work for which thisFixed Appliances Not Over i HP CITY Tel No 0 permit is issued 1 shall not employ any person in any manner PERMIT i () so as to become subject to the Workers' Compensation Lawn Range_ Heater_O W APPLICANT W Oven Dryer_W M _ ADDRESS �/ 2 CL ul Date Applicant Top FAU _W H Hood Fen _Other_ CITU Tel No NOTICE TO APPLICANT If after making this Certificate of Dlsp _ Room Air Cond_ LI SE Exemption, you should become subject to the Workers REQ NUMBER Class Compensation provisions of the Labor Cade you must forth Power Apparatus& Large Appliances DISTRICT NO PROLE SED BY with comply with such provisions or this permit shall be deemed revoked Size&Type HP,KW,KVA or KVA S!A Up to 1 Incl Over 1 to 10 Incl FINAL LICENSED CONTRACTORS DECLARATION DATE Over 10 to 60 Incl VALIDATION 1 hereby affirm that 1 am licensed under provisions of Chapter Over 50 to 100 Inc FINAL f � 9 (commencing with Section 7000) of Division 3 of the Busi Over 100 BY 1--"--'�— nese and Professions Code, and my license is in full force and affect Services License Numb Lic Class 0.200 Amp Under 600 V �� 10 201 1000 Amp Under 600 V SS 3 9 3 0 E 0 A Contmcto ate— t Over 1000 Amp or Over 600 V HOME OWNE BUILDER DECLARATION # • • • • • 2 Temp Power Pole&Appurtenances I hereby affirm that 1 am exempt from the Contractor's Sign with One Branch Circuit 2 • • 4$ 9 7 License Law for the following reason (Section 7031 5, Bust Additional Sign Branch Circuits • • • 4 8 9 7 nm and Professions Code) I as owner of the property will do the work and the Mix Conduits&Conductors Other(See Complete Fee Schedule)— 1 1 13 -80 structure a not intended or offered for sale (Section7044, Business and Profesatons Code) CONSTRUCTION LENDING AGENCY I 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 Cry C) Lender s Name PLAN CHECKING FEE (One-Fourth Permit Fee) Lender's Address PERMIT ISSUING FEE 1 certify that I have read this application and stale that the TOTAL FEE above information is correct 1 agree to comply with all County �ev ordinances and State laws regulating Electrical wiring and p 7 hereby authorize representatives of this County to enter upon 9the above me tioned properly or inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE 11, 13 - 90 Signature of P trice Date WORKERS COMPENSATION DECLARATION CES636G (2 601 APPLICATION FOR ELECTRICAL PERMIT 76 6 U I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY sure, or��ppliii certificate of Workers'Compensation Insurance,or 1 certifop sof(SepL3j170 a C) - `��// �� / 7 �7� _ rI FOR APPLICANT TO FILL I J06 PD is C mpe y /1Is4 OSI EACH NO FEE ADDRESS 6351 Temple CityBoulevard ��//JJ�� New Residential Bldgs &Pools Z IfI copy rs ereby wished //� �� 1 &2 Famdy,Sq Ft $ — $ LOCALITY Temple City, California Certified copy n filed with the county budding inspection Multi-family Sq Ft CROSS ST LOR don department Residential Swimming Pools OWNER OR FIRM NAME J. H. Hedr Ck & Co. Date Applicant Outlets Rec_LightSw _ MAIL 0 I must 20 CERTIFICATE OF EXEMPTION FROM WORKERS' Total No Additional CITY San Gabriel Tel No 287-9721 } COMPENSATION INSURANCE 1 PLAN CHECK O (This section need not be completed if the work inLig volved APPLICANT L) hting Fixtures20 by the permit is for one hundred dollars (f100) or Tess) Additional ADDRESS Total No — I certify that in the performance of the work for which this Fixed Appliances Not Over 1 HP CITY Tel No 1 U permit is Issued, I shell not employ any person in any manner PERMIT W so as to become subject to the Workers' Compensation Laws Range_ Heater DW APP IC NT J. H. Hedrick & CO. y �• '1 Oven _ Dryer_W M ADOREbS 900 So. San Gabriel Blvd. Z Date li�3�$C Applicant ..1. �. r�'G 17Q121t ��, Top — FAU _WH Hood _ Fen _Other_ CITY San Gabriel Tribe, 287-9721 NOTICE TO APPLICANT If after making this Certificate of Disp _Room Air Cond_ LICENSE OR Exemption, you should become subject to the Workers REG NUMBER 156407 Class Compensation provisions of the Labor Cade you must forth Power Apparatus& Large Appliances DISTRICT NO PRWESSEO BY with comply with such provisions or this permit shell be Size&Type HP KW KVA or KVAR DU CC deemed revoked Up to 1 Incl FINAL Over 1 to 10 Incl DATE Y7r LICENSED CONTRACTORS DECLARATION Over 10 to 50 Incl //—/ �Ilj v VALIDAN 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 Busi Over 100 BY i, ness and Professions Code, and my license is In full farce and effect Services License Number Lie Clev 0 200 Amp Under 600 V 201 1000 Amp Under 600 V Contractor Date Over 1000 Amp or Over 600 V HOME OWNER-BUILDER DECLARATION Temp Power Pole&Appurtenances o o C/✓� I hereby affirm that I em exempt from the Contractor's Sign with One Branch Circuit License Law for the following reason (Section 7031 5, Bust Additional Sign Branch Circuits ness and Professions Code) _ I, as owner of the property will do the work and the Mix Conduits&Conductors Other (See Complete Fee Schedule)— 2 9 0 4 A structure is not intended or offered for sale (Section 7044, Business and Professions Code) • • 2 CONSTRUCTION LENDING AOENCY I hereby affirm that there is a construction lending agency 2 a 1 7 0 0 for the performance of the work for which this permit is PERMIT FEE (Sub-Total) issued(Sec 3097 Civ C) • ,7 0 0 U Lender's Name PLAN CHECKING FEE (One-Fourth Permit Feel i 1103-80 Lender's Address PERMIT ISSUING FEE I certify that I have read this application and state that the TOTAL FEE 7 01, ' above information is correct I agree to comply with fill County ordinances and State laws regulating Electrical wiring and - hereby authorize repreaentatives of this County to enter upon the above men lio ed property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE �n�... ,. //- 3-30 Signature of Permittee Date