HomeMy Public PortalAbout6355 TEMPLE CITY BLVD_Electrical__ WORKERS'COMPENSATIONDECLARATION 76A663CE 78,4883 12801 APPLICATION FOR ELECTRICAL PERMIT {�
LlI hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELEP BUILDING AND SAFETY
Insure ogQr a certificate ofWorkers'
`yCompensation Insurance,or
Polity No�� e�o Company.6 Sv. d00✓! / su /1�
Bldgs &P IFOR APPLICANT TO FILL IN JOB
New Residential BI EACH NO FEE ADDRESS
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❑ Certifled copy is hereby furnished I &2-Famdy,Sq Ft 79 S o — $ LOCALITY
Multifamily Sq Ft NEAREST
Certified copy n filed with the county budding mspe Own CROSS ST
o art ant Residential Swimming Pools OWNER OR
FIRM NAME
Dat pplicant Outlets Rec_Light_Sw _ MAIL ano ) L
First 20 ADDRESS///
CERTIFICATE OF EXEMPTION FRO WORKERS Total No Additional CITY el No
PL
COMPENSATION INSURANCE pY,
AN CHET ^
APPLICANT
(This section need not be completed If the work mvotved
by the Lighting Fixtures Fant i20
o ADDRESS
permit u for orre hundred doBara (St00) m less) Total No — Addmonel Cr certify that in the performance of the work for which this Fixed Appliances Not Over 1 HP CITY Tel No O
permit is issued, I shall not employ any person In any manner PERMITI U
so as to become subject to the Workers Compensation Laws Range_Hester_DW _ APPLICANT N
Oven _ Dryer_W M _ ADDRESS
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Date Applicant Top _ FAU _W H
Hood _ Fan _Other CITU Tel No S 3
NOTICE TO APPLICANT If after making this Certificate of Disp _ Room Air Cond_ L C O S CI•u —/0
Exemption, you should become subject to the Workers REG NUMBER �
Compensation provisions of the Labor Code, you must forth Power Apparatus& Large Appliances DISTRICT NO PROCESSED By
with comply with such provmons or this permit shall be Size&T
deemed revoked Type HP KW KVA or KVA
Up to 1 Incl
FINAL
LICENSED CONTRACTORS DECLARATION ��ff
Over 1 to 10 Incl DATE�'��O �� VALIDATION
Over 10 to 60 Incl
I hereby affirm that 1 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 (news and Professions Code, and my license Is In full force and o
effect Services /
License Number Dl� Lic Class 0 200 Amp Under 600 V
l�f
201 1000 Amp Under 800 V
Contracto Date Over 1000 Amp or Over 600 V
HOME OWNE BUILDER DECLARATION Temp Power Pole&Appurtenances
1 hereby affirm that I am exempt from the Contractors Sign with One Branch Circuit Additional Sign Branch Circuits .3 04.7 A
License Law for the following reason (Section 7031 5 Bust
ness and Professions Code) # • • • • • 2
Misc Conduits&Conductors -
❑ 1, as owner of the property will do the work and the Other(See Complete Fee Scheddle)— 2 • • 4 Q 9 7
structure is not intended or offered for sale (Section
7044, Busmess and Professions Code)
CONSTRUCTION LENDING AGENCY • • • 4 8 9 7
1 hereby affirm that there Is e construction lending agency 1 1 13-80
for the performance of the work for which this permit is PERMIT FEE (Sub Total)
issued (Sac 3097 Civ C) -
Lender's Name PLAN CHECKING FEE (One Fourth Permit Fee)
Lender's Address PERMIT ISSUING FEE v
I certify that I have read this application and state that the TOTAL FEE
above Information is correct I agree to comply with all County ��/
ordinances and State laws regulating 41ectrical wiring and 7
hereby authorize representatives of this County to enter upon
the above mentioned property for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
ignature of ermittee Date