HomeMy Public PortalAbout9553-9555 WOODRUFF AVE_Electrical__ WORKER'S COMPENSATION DECLARATION 20.0019 DPW(12-91) �••�tPPlt„�CA U 0®. FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self Insure, 78A663 1'i!{/9
or a certificate of Worker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS BUILDING AND SAFETY DIV.
copy thereof(Sec.3800 Lab.C.)
Policy ND. 230735 cORA�i f i c National I FOR APPLICANT TO FILL IN gDDRES ,a1 IA 1>ni
Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE LOCALITY TEMPLE CITY, CALIF.
i &2-Family,Sq.Ft. — $ $
Certified copy is filed with the county building inspection _ NEAREST
departme Multi-family Sq.Ft. CROSS ST.
Date r Applicant G• & S . E 1 e c t r Residential Swimming PoolsASAP BOOK I PAGE PARCEL
CE TIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec._Light Sw. FIRMNAME M R. & MRS. S O O H 0 0
COMPENSATION INSURANCE p First 20
(This section need not be completed If the work Involvod by the ` ADDRESS
permit is for one hundred dollars($100)or less.) Total No. Additional
I certify that in the performance of the work for which this permit CITY el
Is issued, I shall not employ any person in any manner so as to PLAN CHECK
become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 APPLICANT
Total No. Additional ADDRESS
Date Applicant RESIDENTIAL APPLIANCES NOT OVER 3 HP.
NOTICE TO APPLICANT: If, after making this Certificate of CITY Tel.No.
Exemption,you should become subject to the Workers'Compensation Q OTHER APPLIANCES NOT OVER 3 HP.
provisions of the Labor Code, you must forthwith comply with Such PERMIT
APPLICANT G, & $. ELECTRIC
provisions or this permit shall be deemed revoked. C Power Apparatus&Large Appliances
LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS 531 S. ATLANTIC BLVD.
I hereby affirm that I am licensed under provisions of Chapter 9 Over 3 to 10 Incl.
(commencing with Section 7000)of Division 3 of the Business and CITYMO N T E R E Y PARK Tal-+213 )283- 317
Professions Code,and my license is In full force and effect. Over 10 to 50 Incl. LICENSE OR 2 4 8O5 7 Class. C 1 0 I_
Over 50 to 100 Incl. REG.NUMBER
License Number O
2 4 8 0 5 7 Lic.Class C 1 0 Over 100 DISTRICT NO. ESSED BY U
'
Pelltiq
Contractor G . & S . E L E C T UC y/39s Amp.under o VNO FINAL
DATE q O
F1a' 400-1000 Amp.Under 600 V
I am exempt under Sec. _E
Over 1000 Amp.or Over 600 V VALIDATION W
FINAL a-
B.&P.C.for this reason BRANCH CIRCUIT FEES BY Z
Date: 15A,or 20A,120V,Lighting or Recept.
1 To 10 Branch Circuits
Signature 11 To 40 Branch Circuits
❑ 41 Or More Branch Circuits
Exemption for Reg.ivit.Elect. 15A,20A,208V To 277V Lighting Br.Circuits
SINGLE FAMILY Temp.Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License La _
for the following reason (Section 7031.5, Business and ProfessloAdditional Sign Branch Circuits
Code): _
❑ I,as owner of the property,will do the work and the structure Misc.Conduits&Conductors
is not Intended or offered for sale(Section 7044, Business Other(See Complete Fee Schedule)
and Professions Code).
CONSTRUCTION LENDING AGENCY
hereby affirm that there is a construction lending agency for the
performance of the work for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total) (r
Civ.C.)
PLAN CHECKING FEE __ ,_
Lender's Name
PERMIT ISSUING FEE eA 41 o I °••'-
Lender's Address
I certify that I have read this application and under penalty of purjury state TOTAL FEE I
that the above information is correct. I agree to comply with all County
ordinance nd State laws regulating Electrical wiring,and hereby authorize
represen i sof thisPurity to enter upon the above-mentioned property
for insp purpos SEE REVERSE FOR EXPLANATORY LANGUAGE
P-MMATURE 09-7"'--
ETT DATE