HomeMy Public PortalAbout5124 ROSEMEAD BLVD_Electrical__ WORKER S'COM PENSATION DECLARATION CE866� (2-80) APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY
insure, or a certificate of Workers'Compensation Insurance,or i
a certified copy thereof(Sec. 3800,.Lab.C.)
FOR APPLICANT TO FILL IN JOB Policy'No. Company EACH NO. FEE ADDRESS
New Residential Bldgs.&Pools
Certified copy is hereby furnished. 1 &2-Family,Sq. Ft. _ DO $ 0 — $ LOCALITY C j
❑ Multi-family Sq. Ft. NEAREST
Certified copy is filed with the county building inspection CROSS ST
department. Residential Swimming Pools OWNER O'R s
Is U"ilr`S FIRM NAME
Date Applicant Outlets: Rec.—Light— ADDR
Firstrst 20 ESS .592-9— W— A/ 1521-,.
CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. Additional CITY 1—� , r Tel No.
COMPENSATION INSURANCE PLAN CHECK a
(This section need not be completed if the work involved APPLICANT O
by the permit is for one hundred dollars ($100) or less.) Lighting Fixtures First 20 ADDRESS
Additional
Total No. O
I certify that in the performance of the work for which this Fixed Appliances Not Over 1 HP CITY Tel No.
m
permit is issued, I shall not employ any person in any manner PERMIT �• W
so as to become subject to the Workers' Compensation Laws. Range_ Heater_D.W. APPLICANT L a
Oven Dryer_W.M. ADDRESS N
Date; �ZApplicant /��/7�L,7�C/d`lIC�C. [CJ Top — FAU —W.H..— .
721
Hood _ Fan _Other_ CITY Tel No.
NOTICE TO APPLICANT: If, after making this Certificate of Disp. _ Room Air Cond. LICENS OR
Exemption, you should become subject to the Workers' REG. NUMBER ' '� Class 4^1veC<
Compensation provisions of the Labor Code, you must,forth- Power Apparatus& Large Appliances DISTRICT NO. PROCE ED BY
with comply with such provisions or this permit shall be
deemed revoked. Size&Type HP,KW, KVA,or KVAR
Up to 1 Incl.
FINAL �.
VALIDATION
LICENSED CONTRACTORS DECLARATION Over 1 to 10.Incl. DATE r -
Over 10 to 50 Incl. P
I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. FINAL
9 (commencing with Section 7000) of Division 3 of the,Busi- Over 100 BY
ness and Professions.Code, and my license is in full force and
effect. Services / r
/Z�S�'-_ Lic.Class C-7"O 0-200 Amp. Under 600 V 6 C t' / �r L
License Number
201-1000 Amp. Under 600 V
Contractor44 aC_-r= Date 3J�� f-z Over'1000 Amp.or Over 600 VC'r��
ew
HOME OWNER-BUILDER DECLARATION Temp. Power Pole&Appurtenances J] ChMvS w✓�t'��
I hereby affirm that I am exempt from the Contractor's Sign with One Branch Circuit
License Law for the following reason (Section 7031.5,Busi- Additional Sign Branch Circuits
ness and Professions Code):
Misc.Conduits&Conductors
MI, as owner of the property, will do the work and the Other (See Complete Fee Schedule)— 3 3 9 1 A
structure is not intended or offered for sale (Section
7044, Business and Professions Code).
�
that
LENDING AGENCY � °10'per�o ?
I hereby affirm there is a construction lending agency
for the performance of the work for which this permit is
issued (Sec. 3097,Civ.C.). PERMIT FEE (Sub-Total) A- o'0 1 ] �,' Q U
r
Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee) G 03,25-82
Lender's Address PERMIT ISSUING FEE Q 'J O
I certify that I have read this application and state that the TOTAL FEE j70 Sa
above information is correct. I agree to comply with all County
ordinances and State laws regulating Electrical wiring, and
hereby authorize representatives of this County to enter upon
the ab mentioned property for inspection purposes. SEE'REVERSE FOR EXPLANATORY LANGUAGE
3 Ze2^
Si nature of Permittee Date