Loading...
HomeMy Public PortalAbout6357 TEMPLE CITY BLVD_Electrical__ WORKER S'COMPENSATION DECLARATION 1 76A663 63 (2 801 CE8 • • ` APPLICATION FOR ELECTRICAL PERMIT I hereby ,dorm that I have a certificate of consent to self COUNTY OF LOS ANGELES p BUILDING AND SAFETY insure or a certificate of workers'Compensation Insurance,or L' Icertihed co thargo ( c 38�{,pb Cp� � ,VY v FOR APPLICANT TO FILL IN JOB Policy N � o pant ADD RE 55 New Residential Bldgs &Pool EACH NO FEE Certified copy is hereby furnished 1 &2 Family.Sq Ft - � S O,] — S LOCALITY Certified to D is filed with the county budding inspection Multi-family Scl Ft — T KF Residential Swimming Pools CROSS ST de an t ^ OWNER M lI// )({gyp, FIRM NAME Date plicent Outlets Rec_Light Sw _ MAIL Inst 20 ADD SS CERTIFICATE OF EXEMPTION FROM RKERS' Total No Additional CITY T el No COMPENSATION INSURANCE d ll PLAN CHECK ^ APPLICANT (Thu section need not be completed if the work Involved Lighting Fixtures First io ADDRESS by the permit u for one hundred dollars (5100) or less) Total No Additional � I certify that in the performance of the work for which this Fixed Appliances Not Over 1 HP CITY Tel No 0 permit is issued I shall not employ any person in any manner PERMIT so as to become subject to the Workers' Compensation laws Range_Heater_D WAPPLICANT Oven _ Dryer_W M _ ADDRESS N 2 Date Applicant Top _ FAU —W H _ Hood — Fan _Other— CITY Tal No NOTICE TO APPLICANT If after making this Certificate of Cup _ Room Air Cond_ LICE OR �) Exemption you should become subject to the Workers' REG NUMBER !/ Clan Compensation provisions of the Labor Code, you must forth Power Apparatus& Large Appliances DISTRICT NO PR OCE SED BY with comply with such provisions or this permit shall be deemed revoked Size&Type HP,KW, KVA,or KVA �/O y Up to 1 Incl FINAL LICENSED CONTRACTORS DECLARATION Over 1 to 10 Incl DATE CO � VALIDATION, Over 10 to 50 Incl hereby affirm that 1 am licensed under provisions of Chapter Over 50 to 100 Inc FINAL �. 9 (commencing with Section 7000) of Division 3 of the Bust Over 100 By nese and Professions Code and my license is in full force and effect V Services / License Number W ` Lic Class 0 200 Amp Under 600 V 201 1 ODD Amp Under 600 V S,S..30 ontracto ate Over 1000 Amp or Over 600 V HOME OWNER BUILDER DECLARATION Temp Power Pole& Appurtenances I hereby affirm that 1 am exempt from the Contractor's Sign with One Branch Circuit License Law for the following reason (Section 7031 S Bust Additional Sign Branch Circuits _43 0 Q 6 A nm and Professions Code) # • • • • • 2 Misc Conduits&Conductors F1 I as owner of the property will do the work and the Other (See Complete Fee Schedule)— structure is not intended or offered for tele (Section 2 • • 4 Q 9 7 7044 Business and Professions Code) 4 8 9 7 CONSTRUCTION LENDING AGENCY 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) I ) ) 3 -80 issued (Sec 3097 Cw C) Lender s Name PLAN CHECKING FEE (One Fourth Permit Fee) Lender's Address PERMIT ISSUING FEE 1 certify that 1 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 the bove mentioned property for inspection purpo SEE REVERSE FOR EXPLANATORY LANGUAGE ignature of Peripittee Date ION 'WORKER Save a certificate of consent to 211IM83 Ply(12 81) APPLICATION FOR ELECTRICAL PERMIT IJ I hereby efOrm Ihat9 have a cerincete of consent to sell meure or a cenifiynte of Worker a Compensation Insurance or a certified COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV copy thersol(Sao338DO Lab C) 78g^ Policy No ' � CompenY.G�i1 rG �U�� FOR APPLICANT TO FILL IN JADDRE66 Cemfied copy Is hereby furnished New ResidentuJ Bldgs 8 Pods NO EACH FEE r LOCALITY Certified copy A filed with the county budding Inspection 1 8 2 Family Sq Ft /�tlepadmem Mufti family Sq Ft — C�6� I. Date_AppliCent� ® L Residential Swimming Poole ASSESSOR . NAP BOOKS ZPAGE PARCEL COMPENSATION INSURANCE CERTIflCOF EXEMPTION FROM WORKERS Outlets Ree aught Sw Oy01ER OR COFlRM NAME (This"oil" need not be completed if the work Involved by the Fant 20 MAL - .� permit Is for one hundred dollars(6100)or lees) Total No � Additional ADDRESS /7 CIAAQ I certify that in the performance of the work for which this permit C: TO No is issued I shall not employ any person in any manner so as to become subject to the Workers Compensation Laws Lighting Futures First 20 PIANAN Cc E K Total No Additional ADDRESS Dere MDlfrmt RESIDENTIAL APPLIANCES NOT OVER 3 HP NOTICE TO APPLICANT It alter making this Certificate of CRY TN Fb Exemption you should become subject to the Workers Compensation OTHER APPLIANCES NOT OVER 3 HP provisions of the Labor Code you must forthwith comply with such PERAtrz prowalona_or this permit shall be deemed revoked Power Apparatus 8 Large Appliances APPL�ANT LICENSED CONTRACTORS DECLARATION Sim d Type HP KW KVA or KVAR ADDRESS I hereby affirm that I am licensed under provisions of Chapter B Over 3 to 10 Incl(commencing with Section 7000)of Division 3 of the Business and CITY r s Tel No Professions Cade and my license Is in full force and effect Over 10 to 50 Ind ECCIW a Over 50 to 100 Ind RLIEOCENSNWtBER Over 100 DISTRICT NO 99ED BY V License Number Uc Class l�,L� JD� yeF ' ,,.,s Services Swbd MCC 8 Panelboards �icc Contractor)M ©,I.QWq Data 0 389 Amp Under 600 V wTE (� ❑ I am 00 exempt under Sec 400 1000 Amp Under 8 V LD� ' ` VALIDATION V Over 1000 Amp or Over 600 V FINAL d B 8P C for this reason BRANCH CIRCUIT FEES ar f / (n Date 15A or 20A 120V Ughting or Recept Z Signature 1 To 10 Branch Circuits 11 To 40 Branch Ce ,M ❑ Exemption for Reg Mmnt Elect154,20A 2D6V To 27NLiLighting Cfe Br Branch Gnaxts Cwcuro 2 SINGLE FAMILY Temp Power Pde d Appurtenances CT.. HOME OWNER BUILDER DECLARATION tAGri 1 hereby affirm that I em exempt It= the Contractor a Licence Lew Sign with One Branch Circuit for the following reason (Section 7031 5 Business and Professions Additional Sign Branch Clrceds - - 3 59.&5,Code) ❑ 1 ITEMS I as owner of the property will(to the the work and the structure MistConcurs,E Conductors is not Intended or offered for sale (Section 7044 Business Other(See Complete Fee Schedule)_ , TOTAL 59 .85 and Professions Code) GHECK 59.85 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the Performance of the work for which this permit is issued(Sec 3087 PERMIT FEE (Sub-Total) Civ C) PLAN CHECKING FEE OO OS 5/24/93 Lander a Name PERMIT ISSUING FEE q7s 9888 1 AM 8:47 Landera Address I certify that I have read this appicahon and under penalty of purJury state TOTAL FEE that the above information is correct I agree to comply with all County ordmencet and Slate Im"regulaling Electrical wiring andherebyautfo x, representatives of fine County to enter upon the above mentioned property for Inspection purpose SEE REVERSE FOR EXPLANATORY LANGUAGE ??-93 sxi aF PEwA1T oATa '�