HomeMy Public PortalAbout5629 ROSEMEAD BLVD_Electrical__ WORKER'S COMPENSATION DECLARATIONeSDPw9fes APPLICATION FOR ELECTRICAL, PERMIT
I hereby afflrrir'that I have a certificate of consent to self insure,
or a.4clificate of Worker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT.*F PUBLIC WORKS BUILDING AND SAFETY DIV.
copy thereof(Sec.3800 Lab.C.)
Policy No. COmpan ND FOR APPLICANT TO FILL IN JOB
ADDRESS s
Certified copy is hereby furnish'
e EACH NO. FEE !•
New Residential Bidg's.&Pools LOCALITY
❑ Certified co with the c u ng Ins c Ii 1&2-Family,Sq.Ft. $ — &.
de Multi-family Sq.Ft. — NEAREST
CROSS ST. + V -
Date Applicant :� Residential Swimming Pools ASSESSOR
MAP BOOK PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rea.._Light Sw. OWNER OR
COMPENSATION INSURANCE I FIRM NAMEi�
First 20 MAIL
(This section-need not be completed If the;work Involved•by the ADDRESS
Total Na. Additional �.
permit Is.for one hundred dollars($100)or'less.) I
,I certify that In the performance of the work for which this permit. CITY T.I.No. � (�
Is issued, I shells not employ any person In any manner so as to PLAN CHECK
become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 APPLICANT '`(7i
Total No. Additional q 9.S`� r
ADDRESS r Y •-fJ
Date Applicant 15 OR MA,120V BRANCH CIRCUITS
NOTICE TO APPLICANT: If, after making this Certificate of CITY t+� Tel.No.
Exemption,,you.should become subject to the Workers'Compensation 'I'TO 10 INCLUSIVE EACH
,provisions of the Labor Code,you must forthwith comply with such 11 TO 40 INCLUSIVE EACH PERMIT t Sl
APPLICANT
provisions or this permit shall be deemed revoked. 4:1 OR MORE BRANCH CIRCUITS:EACH I �.
LICENSED CONTRACTORS DECLARATION ADDRESS 4fv •0
.hereby affir I am licensed-under provisions of Chapter 9 15 OR 20A,208V TO 277V LIGHTING EACH
(commencing with ction 7000)of Division 3 of the Business and CITY Tel.No. L
Professions Code . d my license is in full force and effect: RESIDENTIAL APPLIANCES UP TO SHP LICENSE OR � Class Q
Power Apparatus'&Large Appliances REG.NUMBER �r�I J�
Liven r LIC.-Class Size&Type HP,KW,KVA,Or KVAR DISTRICT N0. PROCESSED BY V
Up to 3 Incl J6�0�
W
Over 3 to 10 Incl. FINAL a
Cohtre . Date DATE z
Over 10 to 50 Incl. �y Z
❑' I am exempt,under Sec. Over 50 to 100 Incl. eG�� VALIDATION
Over 100 FINAL
BAP.C.for this reason BY
Services,Swbd.,MCC&Panelboards ;
Dam' 0.-200 Amp.Under 600 V
Signature 201--1000 Amp.Under 800 V•--;
El
Over 1000 Amp.or Over 600 V
Exemption for Reg.Malnt.Elect.
SINGLE FAMILY Temp.Power Pole&Appurtenances q
HOME OWNER-BUILDER DECLARATION ! - f(•L•!-'e
I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit
for the following reason (Section.7031.5, Business and Professions Additional Sign Branch Circuits'
Code):
' + � 4
❑' I',as owner of the property,will do the work and the structure Misc.Condufts&Conductors
1.y. ij =w� =-r_.
is not Intended or offered for sale(Section 7644, Business Other(See Complete Fee Schedule) ! •- --" _ =s
and Professions Code). , I ;:-ti; 59 I55.
CONSTRUCTION LENDING AGENCY
I 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) '
Civ.C.)
t PLAN CHECKING FEE l '-x.E`I�j�t=� ����!'
Lender's Name a� ;+ AW,^IN-+.'c
PERMIT ISSUING FEE '
Len is Ad ss �S
I c rtify that have read.this application and state that the.above TOTAL FEE
information is or I.agree to comply with all County ordinances
an .S w egulatin lectrical wiring, and hereby authorize
r
as at oft u ty to enter upon the above-mentioned
p ope tl r sp to ur ores SEE REVERSE FOR EXPLANATORY LANGUAGE
SI F APPLICANT OR AGENT .DATE ,+