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HomeMy Public PortalAbout5128 ROSEMEAD BLVD_Electrical__ WORKER S'COMPENSATIONDECLARATION CE-806G (2-801 CAPPLICATION 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 EACH NO. FEE ADDRESS5/2& ONew Residential Bldgs.&Pools Certified copy is hereby furnished. 1 &2-Family,Sq. Ft. $ — $ D LOCALITY ElCertified Sq. Ft. — NEAREST OV Certified copy is filed with the county,building inspection CROSS ST department. Residential Swirpming Pools OWNER OR / - - rJ19/J7`S FIRM NAME f Ire Date Applicant Outlets: Rec.—Light—Sw. MAIL t First 20 ADDRESS_>-->2s AI golf— CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. Additional CITY r A�r � �� Tel No. COMPENSATION INSURANCE PLAN CHECK a APPLICANT (This section need not be completed if the work involved 0 Additional by the permit is for one hundred dollars ($100) or less.) Lighting Fixtures, First ADDRESS ' IY Additional Total No. Q I certify that in the performance of the work for which this Fixed Appliances Not Over 1 HP CITY Tel No. U permit is issued, I shall not employ any person in any manner PERMIT �` LL so as to become subject to the Workers' Compensation Laws. Range_ Heater_D.W. APPLICANT + T�� CD p_ Oven Dryer_W.M. ADD.RESS b-S- Z Top — FAU _W.H..Dat0.�--Applicant Hood — Fan _Other_ CITY Tel No. NOTICE TO APPLICANT: If, after making this Certificate of Disp. _ Room Air Cond.— LICENSE OR 4n­/0Exemption, you should become subject to the Workers' REG. NUMBER ��$� Class Compensation provisions of the Labor Code, you must forth- Power Apparatus& Large Appliances DISTRICT NO. PROCES ED BY with comply with such provisions or this permit shall be Size&Type HP,KW, KVA,or KVAR deemed revoked. Up to 1 Incl. FINAL Over 1 to 10 Incl. DATE LICENSED CONTRACTORS DECLARATION Over 10 to 50 Incl. �1_5 _3 VALIDATION I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. FINAL BY 9 (commencing with Section 7000) of Divisiori 3 of the Busi- Over 100 ness and Professions.Code, and my license is in full force and effect. 7 Services v License Number s�SfJ� Lic.Class �-/� 0-200 Amp. Under 600 V q ©� �� e Cl0 / 201-1000 Amp. Under 600 V ' Contractor a-/4 Date 3 Over 1000 Amp.or Over 600 V Cc�.tT. HOME OWNER-BUILDER DECLARATION Temp. Power Pole&Appurtenances Sign with One Branch Circuit I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): c 339.4A Misc.Conduits&Conductors I, as owner of the property, will'do the work and the Other (See Complete Fee Schedule)— 0 0 o o o 2 structure is not intended or offered for sale.(Section 7044, Business and Professions Code). 2 - .1 59.70 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency 0 P(, 1 5 9,7 0 0. for the performance of the work for which this permit is PERMIT FEE (Sub-Total) issued (Sec. 3097,Civ.C.). S�.� d 0325-82 Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee) Lender's Address PERMIT ISSUING FEE �Q I certify that I have read this application and state that the TOTAL FEE �- above information is correct. I agree to comply with all County ��/ 70. 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 SignWfure of Permittee Date