HomeMy Public PortalAbout5636 ROSEMEAD BLVD_Electrical__ WORKERS"COMPENSATION DECLARATION `76806 10/81 APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self PE-806G APPLICATION
insure, or a certificate of Workers'Compensation Insurance, I COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified copy thereof(Sec. 3800, Lab. C.)
Policy No. Company FOR APPLICANT TO FILL IN JOB
Certified copy is hereby furnished. New Residential Bldgs. &Pools EACH RESS
NO. FEE ADD
Certified copy is filed with the county building inspec- I 1 &2-Family, Sq. Ft. $ — $ LOCALITY'
tion department. Multi-family Sq. Ft. — 'NEAREST
Residential Swimming Pools CROSS ST.
Date. Applicant OWNER OR T
FIRM NAME _„(
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec MAIL
/.
COMPENSATION INSURANCE. Light SFirst 20w._ ADDRESS
(This section need not be completed if the work involved by i Total No. CIN~ Tel. No.
the permit is for one hundred dollars($100)or less.) Additional e
I certify that in the performance of the work!or w ich this I APPLICANT
permit is issued, I shall not employ any per n i manner j
so as to be me s b'ect to the Workers' n tion Laws. Lighting Fixtures First 20 ADDRESS
I ( ISive.
Total No. Additional
a. I CITY�� Tel. No. 7 ��.
Date pplica Fixed Appliances Not Over 1 HP PERMIT
NOTIC TO APPLICANT: If, afer,ma .ng this Certificate of
Exemption, you should become subject to the Workers' Range_ Heater_D.W. I APPLICANT Q
Compensation provisions of the Labor Code, you must forth- I Oven —Dryer —W.M.— ADDRESS
with comply with such provisions or this permit shall be Top _ FAU W.H. —
deemed revoked. Hood _ Fan _Other_ CITY Tel. IVo.
LICENSED CONTRACTORS DECLARATION ++ 30 LICENSE OR
1 hereby affirm that I am licensed under provisions of Chapter 9 Disp. _ Room Air Cond. l REG. NUMBER Class.li Q
(commencing with Section 7000)-of Division 3 of the Business' DISTRICT NO. PROCES BY
and Professions Code,and my license is in full force and effect. I Power Apparatus 8 Large Appliances
Size&Type HP, KW, KVA, or KVAR' O
License Number Lic. Class L'-Jd Up to 1 Incl. FINALQ V
Contract Date ( i Over.1 to 10 Incl. DATE O ✓ VALIDATION 8
1:1Over 10 to 50 Incl. FINAL
I am exempt under Sec. Over 50 to 100 Inc. BY r-� ti-.�_
Over 100
BAP.C. for this reason V
CC 8 Panelboards
Date: r 0 -200 Amp. Under 600 V 4
Signature 201 - 1000 Amp. Under 600 V
❑ Exemption for Reg. Maint. Elect. Over 1000 Amp. or Over 600 V
SINGLE FAMILY I Temp. Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit -Z 4 1 0 8 A
I hereby affirm that I am exempt from the Contractor's License Additional Sign Branch Circuits
Law for the following reason (Section 7031.5, Business and d
Professions Code): �, coo ° 0 2
❑ I, as owner of the property, will do the work and the I Misc. Conduits&Conductors 2 0 ' 29.0.0
structure is not intended or offered for sale (Section Other(See Complete Fee Schedule)_
7044, Business and Professions Code). ? ° ° ° 2 9.0 C r
CONSTRUCTION LENDING AGENCY Q (; G 1 —8 3
1 hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued PERMIT FEE -(Sub-Total)
(Sec. 3097, Civ. C.).
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE
Lender's Address
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
ordinances and State laws regulating Electrical wiring, and
hereby auth e r sentatives of this County to enter upon
the above
- a property for inspeetio urpo s.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signa of Permittee Date .