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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