HomeMy Public PortalAbout5126 ROSEMEAD BLVD_Electrical__ WORKERS'COMPENSATION DECLARATION.
CE-806G (2-80) APPLICATION FOR ELECTRICAL PERMIT
CE-806
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 '
a certified copy thereof(Sec. 3800,Lab.C.)
FOR APPLICANT TO FILL IN JOB
Policy No. Company ADDRESS
New Residential Bldgs.&Pools EACH ' NO. FEE �
❑ copy 1 &2-Family,Sq. Ft. (5 $ 83 — $ LOCALITY
Certified co is hereby furnished.' �2 v2
❑ Multi-family Sq. Ft. — NEAREST -
Certified copy is filed with the county building inspection CROSS ST
department. Residential Swimming Pools OWNER OR `���� �
FIRM NAME ;jd& /�-f Ri 6VVIT
Date— Applicant Outlets: Rec.—Light_ Sw. MALL -rte
First 20 ADDRESS. lam/= r✓/Z-r
CERTIFICATE—OF EXEMPTION FROM WORKERS' Total No. Additional CITY L°/Il �L Tel No. a
COMPENSATION INSURANCE PLAN CHECK
(This section need not be completed if.the work involved APPLICANT U
by the permit is for one hundred dollars Fixtures First 20
s ($100) or less.) ADDRESS �.
Total No. Additional 0
1 certify that in the performance of the work for which this Fixed Appliances Not Over 1 HP CITY Tel No.
permit is issued, I shall not employ any person in any manner PERMIT 0 U
so as to become subject to the Workers' Compensation Laws. Range_ Heater—D.W. _ APPLICANT I CL
_ Oven _ Dryer_W.M._ ADDRESS
t� ZS �Z�Z�� Top FAU —W.H. — f z
Date Applicant CITY Tel No.
Hood _ Fan —Other
LLD j— `
NOTICE TO APPLICANT: If, after making this Certificate of Disp. — Room Air Cord._ LICENSE OR C, 99 Exemption, you should become subject to the Workers' REG.NUMBER CEJ Class
Compensation provisions of the Labor Code, you must forth- Power Apparatus&.Large Appliances DISTRICT NO. PROC SSEIQ 6Y
with comply with such provisions or this permit shall be
Size&Type HP,KW,KVA,or KVAR
deemed revoked. {
Up to 1 Incl. FINAL v
Over 1 to 10 Incl. DATE , �s
LICENSED CONTRACTORS DECLARATION g CJ L— VALIDATION
Over 10 to 50 Incl.
I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inca 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
' j(> 0-200 Amp. Under 600 V D L•%�
License Numbe Lic.Classes 0/L 201-1000 Amp. Under 600'V
Contractorao �L=r/. Date 3/2�/fT?v Over 1000 Amp,or Over 600 V
HOME OWNER-BUILDER DECLARATION Temp. Power Pole&Appurtenances
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
❑ I; as owner of the property, will do the work and the Other (See Complete Fee Schedule)—
structure is not intended or offered for sale (Section a 3 3 q 3 A
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY 0 0 0 0 0 2
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is PERMIT FEE (Sub-Total) /�01 �� 2 ° 1 2 1,4 Jr•
issued(Sec. 3097,Civ.C.).
Lender's Namex
PLAN CHECKING FEE (One-Fourth Permit Fee) 0 0 1 2 1,4_5 QLender's Address PERMIT ISSUING FEE
03, 25-82
I certify that I have read this application and state that the TOTAL FEE J�.�
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 above-mentioned property for inspection purposes. SEE'REVERSE FOR EXPLANATORY LANGUAGE
Si'gnature of Permittee Date