Loading...
HomeMy Public PortalAbout4912 ROSEMEAD BLVD_Electrical__ WORKERS' COMPENSATION DECLARATION CE-806G to/at CE-8o6G APPLICATION FOR ELECTRICAL PERMIT I hereby affirm that I have a certificate of consent to self insure, or a certificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY copy thereo?(Sec.3800,Lab. C.) Polirt_✓`�Uo. Company FOR APPLICANT TO FILL IN JOB I �� n ElCertified copy is hereby furnished. New Residential Bldgs.& Pools EACH NO: FEE ADDRESS D f31[U ❑ 1 & 2-Family,Sq.Ft. $ — $ LOCALITY EPt p r Certified copy is filed with the county building inspection department. e Multi-family Sq.Ft. NEAREST CROSS ST. Date Applicant '` Applicant Residential Swimming Pools FORWNER OR M NAME GQ am VJ �� l `AQ CERTIFICATE OF EXEMPTION FROM WORKERS' w. MAIL q R COMPENSATION INSURANCE Outlets:Rec Light t 20 ADDRESS 4,112, D •--N.�1.Gt.G� rJt� (Thissection First 2ection need not be completed if the work involved by the p permit is for one hundred dollars($100) or less.) ' Total No.� Additional CITY ' l_e_ C Tel.No. I certify that in the performance of the work for which this permit PLAN CHECK APPLICANT is issued, I shall not employ any person in-any manner so as to t become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS Additional Total No.� CITY Tel.No. Date Applicant Fixed Appliances Not Over 1 HP PERMIT I NOTICE TO APPLICANT: If, after making this Certificate of I Exemption,you should become subj _ O ect to the Workers'Compensation Range_ HeaterD.W. _ APPLICANT W^Y s provisions"of the Labor Code, you must forthwith comply with such Oven _ Dryer _ W.M._ ADDRESS provisions or this permit shall be deemed revoked. Top — FAU _ W.H. CITY Tel.No. 'LICENSED CONTRACTORS DECLARATION Hood Fan _ Other_ I hereby affirm that I am licensed under provisions of Chapter 9 LICENSE OR Disp. Room Air Cond. REG.NUMBER Class. (commencing with Section 7000) of Division 3 of the Business and Professions Code,and my license is in full force and effect. ' Power Apparatus& Large Appliances DISTRICT NO. P SSE)BY Size& Type HP,KW,KVA,or KVAR 0 License Number Lic.Class Up to 1 Incl. FINAL U Over 1 to 10 Incl. DATE d' Contractor Date VALIDATION 0 ❑ Over 10 to 50 Incl: FINAL I am exempt under Sec. Over 50 to 100 Inc. BY W B.&P.C.for this reason Over 100 N Services,Swbd.,MCC& Panelboards , IFW Z .Date: 0-200 Amp.Under 600 V e� Signature 201 - 1000 Amp.Under 600 V ❑ Over 1000 Amp. or Over 600 V Exemption for Reg.Maint.Elect. SINGLE FAMILY Temp.Power Pole & Appurtenances 2 HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit ACCT I hereby affirm that I am exempt from the Contractor's License Law ACC 1 Y for the following reason(Section 7031.5, Business and Professions Additional Sign Branch Circuits C • +� .yam Code) - = _ L✓J I,as owner of the property,will do the work and the structure Misc.Conduits& Conductors i ITFA ' is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) t1 1 1 i C1k7–g and Professions Code). TOTAL 23.25 " CONSTRUCTION LENDING AGENCY ICY 23.2255 I hereby affirm that there is a construction lending agency for the r� performance of the work for which this permit is issued(Sec.3097, PERMIT FEE (Sub-Total) CHANGE X00 Civ.C.). PLAN CHECKING FEE Lender's Name V VOM"Ml 7 9/29/89 PERMIT ISSUING FEE r ©�7 p�� Lender's Address 5 7 1 certify that I have read this application and-state that.the above TOTAL FEE information is correct. I.agreeto comply with all County ordinances and State I s regulating- Electrical wiring, and hereby authorize representa es of t is County to enter upon the above-mentioned prop y r insp i9Pqpjs2ses. . / SEE REVERSE FOR EXPLANATORY LANGUAGE ature of Permittee Date