HomeMy Public PortalAbout5795 ROSEMEAD BLVD_Electrical__ WORKERS'COMPENSATION DECLARATION 76-663 10/81
CE-8060 APPLICATION FOR ELECTRICAL PERMIT
I hereoy affirm that I have a certificate of consent to self insure, i
or j certificate of Workers'Compensation Insurance, or a certified' COUNTY.OF LOS ANGELES 'BUILDING AND SAFETY
copy thereos(S SOO,LaFj.C.) i
Policy No. ® /Comparry FOR APPLICANT TO FILL IN I JOB
Certified copy.is hereby furnished. EACH NO.. FEE ADDRESS
New Residential Bidgs.&Pools
❑ Certified copy is filed with t county i in 1 &2-Family,S Ft $ _ $ LOCALITY
g ' spection Y, Q' NEAREST
dep rtment Multi-family Sq.Ft. CROSS ST.
�� Residential Swimming Pools
Date'
App liC OWNER OR
I FIRM NAME
ERTIFCATE OF EXEMPTION OM KERS' Outlets:ReC—Light_Sw.— MAIC
COMPENSATION INS RA E . I' ADDRESS
(This'section need not be completed 9 t e rk Involved by the First 20,
permit.is for one hundred dollars($100 IS.
Total No. Additional CITY Tel.No.
I certify that in the performance of the work for which.this permit' PLAN CHECK
-is issued, I shall not employ any pere in any manner so as to.I' APPLICANT
become subject to the Workers'Comp n tion. Lighting Fixtures First 20 ADDRESS '
Additional
i / �. Total No. I. CITY Tel.No.
Date. Applic i
Fixed Appliances Not Over 1 HP ERMIT
NOTIC TO APPLICANT; If, after king his Certi. ate of , l APPLICA
Exemption,you should become subject t the .orker 'Compensation Range_ r. HeateD.W.
provisions of the Labor Code,you must.fort .ith c mply with such l' Oven _ Dryer_ W.M._ ' ADDRESS p�
y
provisions or this permit shall be degmed re ked. . Top FAU _ W.H. _ , .
" LICENSED CONTRACTORS DEC RAJTION Hood — Fan _ Other_ CITY L Tel.N 22W-
LICENSED _
Disp.
I.hereby affirm that I am licensed under prods- ns of Chapter 9 — Room Air Cond. ' LICENSE OR
Clasa.
(commencing with Section 7;000)of Division 3 of the Business and REG.NUMBER SDC3
Professions Code,acid.my license is in full force and effect. Power Apparatus&Large,.Appliances II DISTRICT NO. mz
BY
(' , Size&Type HP,KW,KVA,or KVAR 1 d� O
License Nr—um a4co 6 3 a Lic.,Class01~'/v/�s'/I Up to 1 Incl. FINAL V
t. / _I 1) �!�_/�. Over 1 to 10 Incl. DATE �_ 7 VALIDATION
Contractor c.s/v Date O� l Over 10 to 50 Incl. I0-
FINAL V
❑ I a exempt under.Sec. Over 50 to 100 Inc. BY W
B&P.C.for this reason' !.• Over 100 N
l Services,Swbd.,MCC&Panelboards Z
Date: 0 200.Amp.Under 600 V ,
Signature 201 - 1000 Amp.Under 600 V ,
❑, Over 1000 Amp.or Over 600 V
Exemption for Reg.'Ma;nt.Elect. ,
SINGLE FAMILY Temp.Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
1 hereby affirm that I am exempt from the Contractor's License Law, Additional Sign Branch Circuits
for the following reason.(Section 7031.5,Business and Professions ,= •,
Code): i
.7-1-1
Misc.Conduits&Conductors
I,as.owner of the property,will do the work and the structure!
.is not intended or offered for sale.(Section 7044, Business ,r Other(See Complete Fee Schedule)
and Professions Code). ► TOT
9 55
CONSTRUCTION LENDING AGENCY• E'er/.. - 59
hereby affirm that there is A construction lending agency for the! �.:Fs +�'+:;:•.
performance of the work for which this permit is issued(Sec.3097,'j PERMIT FEE (Sub Total)
Civ;C.): ,
PLAN CHECKING FEE
Lender's Name Y PERMIT ISSUING FEE �.?'�:f-"'L'sj_ / •�`'
Lender's Address ' n27� r
I certify that I have-read this application and state that the above' TOTAL FEE ,• �� �` A i;,' 1 a:I:
information is correct.I agree to comply with all County ordinances.i
and State. laws•regulating Electrical wiring, and hereby authorize'
repre entatives of.this County to enter upon the above-mentioned
pro for i c .n pure ses. SEE REVERSE FOR EXPLANATORY LANGUAGE
915nar of r i e f Date