HomeMy Public PortalAbout6353-6353 1/2 TEMPLE CITY BLVD_Electrical__ WORKERS'COMPENSATIONDECLARATION 76-863
6 APPLICATION FOR ELECTRICAL PERMIT
CEA (2 80)
I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES D �U�LI�IIi AND SAFETY
insure or a certificate
e of Workers'Compensation Insurance or r, ( s q �(
g certified co ppr/fSec7/ V Lgrt �J
Policy i,i. orn any dl FOR APPLICANT TO FILL IN ,r t
❑ New Residential Bldgs &POOI p' EACH NO FEE ADDRESS L �Q
PT
Certified copy is hereby furnished 1 &2 Famdy,Scl Ft 3• 5 1f Is LOCALITY ale r
Certified co Multifamily Scl FtNEAREST
py is filed with the county building maDection CROSS ST
de art en Residential Swimming Pools OWNER OR
FIRM NAME
Date ' ✓Applicant Outlets Rec_Light_Sw _ MAIL
First 20 ADDRESS o v(
CERTIFICATE OF EXEMPTION FROM ORKERS Total No Additional CITveftel No
COMPENSATION INSURANCE }
s PLAN CHECK S
(Thu section need not be completed if the work involved APPLICANT .O
i� by the permit rs for one hundred doBus ($100) or leu) Lighting Fixtures First 20 ADDRESS f..)
I Total No Additional 2
I certify that in the performance of the work for which this Fixed Appliances Not Over 1 HP CITY Tel No 0
Permit a issued I shall not employ any person in any manner t)
so as to become subject to the Workers Compensation Laws Range_Heater PERMIT D W APPLICANT cru
Oven _ Dryer_W M _ ADDRESS
Date Applicant Top _ FAU _W H _ _
Hood _ Fan _Other_ CITU Tel No
NOTICE TO APPLICANT If, after making this Certificate of Disp _ Room Air Cond_ L C
Exemption you should become subject to the Workers REO NUMBER Clan
Compensation provisions of the Labor Code you must forth Power Apparatus& Large Appliances DISTRICT NO PROCE ED V
with comply with such provisions or this permit shall be
deemed revoked Size&Type HP KW KVA,or KVA
Up to 1 Incl O fi
d
FINAL
LICENSED CONTRACTORS DECLARATION Over'l t0101nc1 DATE/1�/O —1// VALIDATION
Over 10 to 50 Incl �l G C
I hereby affirm that I am licensed under provisions of Chapter Over 60 to 100 Inc FINAL
9 (commencing with Section 7000) of Division 3 of the Bust Over 100 BY
neas and Professions Code and my license is in full force and
effect Services ,A
License Number YZZ.D m Clan 0-200 Amp Under 6DO V
201 1000 Amp Under 600 V �J s
Contractor ate Over 1000 Amp or Over 600 V
HOME OW LR BUILDER DECLARATION Temp Power Pole&Appurtenances
I hereby affirm that 1 em exempt from the Contractor's Sign with One Branch Cucu it
License Lew for the following reason (Section 7031 5 Busi Additional Sign Branch Circuits s 3 0 8
nese and Professions Code)
Miss Conduits&Conductors # . . . 2
131, as owner of the property will do the work and the Other(See Complete Fee Schedule)—
structureBu not intended or offered for sale (Section 2 • ( 0.48
7044,
7044, Business
ess end Professions Coda) - V\
CONSTRUCTION LENDING AGENCY • is 9 Q 4 8 P�
I hereby affirm that there is a construction lending agenLy
for the performance of the work for which this permit is PERMIT FEE (Sub Total) I 1 3—8 0
issued (Sec 3097 Civ C)
Lender's Name PLAN CHECKING FEE (One Fourth Permit Fee)
Lender's Address PERMIT ISSUING FEE
N >Y
I certify that I have lead this application and state that the TOTAL FEE • . Ne
above mformation is correct 1 agree to comply with all County • . 6l
ordinances and State laws regulating Electrical wiring and �D � .O • O
hereby authorize representatives of this County to enter upon I O p • P
the above merVioned property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE • -O
s � N a
Signature of Peq ittee bete O
TL