HomeMy Public PortalAbout5922 ROSEMEAD BLVD_Electrical__ WQRKEFI:S COMPEN jATJA
ON DECLARATION f 76Gaoi DPW(12-91) I I
1 hereby affirm that I IIIA a certifirjate of consent to self insure, 63 APPLICATION FOR ELECTRICAL PERMIT LI
or a certificate of Worker's Compensation Insurance, or a certified I COUNTY OF LOS ANGELES DEPT.OF PUBLIC W?RKS BUILDING AND SAFETY DIV.
copy thereof(Sec.3800 Lab.C.)
Policy No. Company FOR APPLICANT TO FILL IN JOB
p y ADDRESS
❑ Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE LOCALITY
❑ Certified copy is filed with the county building inspection 1&2-Family,Sq.Ft. _ $ $ NEAREST �n
department. Multi-family Sq.Ft. CROSS ST. �►6oSQ
Date Applicant
Residential Swimming Pools MAP BOOK I PAGE PARCEL
OWNER OR
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec._Light Sw. FIRM NAME :PUfL&_T
COMPENSATION INSURANCE
First 20 MAIL ��jj�� l'
(This section need not be completed the work Involved by the Total NoAdditional ADDRESS 5021 X N. R 9 a
permit Is for one hundred dollars($7000 .)or less.) p
I certify that in the performance of the work for which this permit CITY Q Tel.No. O$
is issued, I shall not employ any person in any manner so as to PLAN CHECK
become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 APPLICANT
Total No. Additional
ADDRESS
Date Applicant RESIDENTIAL APPLIANCES NOT OVER 3 HP.
NOTICE TO APPLICANT: If, after making this Certificate of CITY Tel.No.
Exemption,you should become subject to the Workers'Compensation OTHER APPLIANCES NOT OVER 3 HP.
provisions of the Labor Code,you must forthwith comply with such PER
Power Apparatus&Large Appliances APPLICANT
provisions or this permit shall be deemed revoked.
LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS
I hereby affirm that I am licensed under provisions of Chapter 9 Over 3 to 10 incl.
(commencing with Section 7000)of Division 3 of the Business and CITY Tel.No.
Professions Code,and my license is in full force and effect. Over 10 to 50 Incl. }
LICENSE OR Class d
Over 50 to 100 Ind. REG.NUMBER
Over 100 DISTRICT NO. P SSED BY O
License Number Lic.Class U
Services,Swbd.,MCC&PanelboardsQ
Contractor Date 0-399 Amp.Under 600 V DATE O
❑ 400-1000 Amp.Under 600 V V
I am exempt under Sec. VALIDATION a
Over 1000 Amp.or Over 600 V
B.&P.C.for this reason I IT
' Data: 15A,or 20A, 20 Llgh ing of r Recap.
1 To 10 Branch Circuits
Signature 11 To 40 Branch Circuits
❑ 41 More Branch Circuits
Li
Exemption for Reg.Maint.Elect. 15A,20A,208V To 277V Lighting Br.Circuits l/ 2
SINGLE FAMILY Temp.Power Pole&Appurtenancesh�./+
HOME OWNER-BUILDER DECLARATION Tn4
I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit ACC
for the following reason(Section 7031.5, Business and Professions Additional Sign Branch Circuits 3303 44.40
Code):
1 ITEMS
"p6 I,as owner of the property,will do the work and the structure Misc.Conduits&Conductors r
Is not intended or offered for sale(Section 7044, Business Other(See Complete Fee Schedule) , Tt�TiLo-�'a o. �'`u 471
and Professions Code). CHECK 44040
CONSTRUCTION LENDING AGENCY CHANGE a 0101
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.) `
PLAN CHECKING FEE 0000001 6/14/96
Lender's Name ... 6918 1 AM 10-'46
PERMIT ISSUING FEE
Lender's Address
I certify that I have read this application and under penalty of purjury state TOTAL FEE
that the above information is correct. I agree to comply with all County
ordinances and State laws regulating Electrical wiring,and hereby authorize
rept entatives of this ounty to enter upon the above-mentioned property
for' action purpos SEE REVERSE FOR EXPLANATORY LANGUAGE
SIG A E OF PER I r DATE ' I .