HomeMy Public PortalAbout6009 ROSEMEAD BLVD_Electrical__ WORKE
ON
I hereby,affi m that I'have�%,cerrtt'ifclate of consentDECLARATION
Oto self insure, 7SM63 DPW(12-91) APPLICATION FOR ELECTRICAL PERMIT
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i;.a.certif,'e"ate of Worker's Compensa&n Irisu ftpoe,or a certified COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS BUILDING AND SAFETY DIV..
copy theXrol(Sec:3800 Lab.C.)
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Policy No. Company FOR APPLICANT TO FILL IN JOB
❑ N.
EACH FEE ADDRESS
Certified copy is hereby furnished. New Residential Bldgs.&Pools NO.
❑ _ $ $ LOCALITY
Certified co Is filed with the county buildin inspection 1&2-Family,Sq.Ft.
PY tY g P _ NEAREST
department. Multifamily Sq.Ft. CROSS ST. 1
Date Applicant r Residential Swimming Pools ASSESSOR
P BOOK PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM'WORKERS' `�
Outlets:Rec OWNER OR FIRM NAME �V v`
' COMPENSATION INSURANCE First 20 -
MW-(This section need not be completed If the work Involved by the ADDRESS4J.sG
permit Is for one hundred dollars($100)or less.) Total No. Additional ,
I certify that in the performance of the work for which this permit CITY T.I.Na.
is issued,'I shall not employ any person in any mariner so as to PLAN CHECK
become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 APPLICANT
Total No. Additional
• ADDRESS t _
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.
pr."ovisions of the Labor Code,you must forthwith comply with such PERMIT
provisions or this permit shall be deemed revoked. Power Apparatus&.Large Appliances APPLICANT
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
Over 50 to 100 Incl. REG.NUMBER Class' }
a
Over 100 DISTRICT NO. VRgCESSED BY V
License Number Lic.Class
Services,Swwbbld.,M C&Pa (boards v
AL
Contractor Date /Q 399 er 600 V - a �' DATE
❑ I am exempt under Sec. 400-1000 Amp.Under 600'V � �l `� VALIDATION W
Over 1000 Amp.or Over 600 V FINAL
B.&R.C.for this reasonBRANCH CIRCUIT FEES BY a)
Date*. 15A,or 20A,120V,Lighting or Recept. Z_
1 To 10Branch Circuits go
Signature I fTo 40 Branch Circuits
❑ - 41 Or More Branch Circuits
Exemption for Reg.Maint.Elect. 15A,20A,208V To 277V Lighting Br.Circuits 2
SINGLE FAMILY Temp.Power Pole&Appurtenances ACCT.4-
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit -+
I hereby affirm that I am exempt from the Contractor',s License Law F303 $j090
for the following reason(Section 7031.5, Business and Professions Additional Sign Branch Circuits 1 ITEMS
Cod}.
guy( I,as owner of the property,will do the work and the structure Misc.Conduits&Conductors TOTAL 82 o 90 '
is not intended or offered for sale(Section 7044i Business Other(See Complete Fee Schedule) CHECK
82.90
and Professions.Code).
CONSTRUCTION LENDING AGENCY CHANGE .00
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.) 0000-0001 3/ 4(96
PLAN CHECKING FEE cJ10 1 Afl10:39
Lender's Name
PERMIT ISSUING FEE O
Lender's Address
I certify that I have read this application and under penalty of purjury state TOTAL FEE
that the above information is coftect. I agree to comply with all County
ordinances and State laws regulating Electrical wiring,and hereby authorize
representatives of this County to enter upon the above-mentioned property
4spkelon purposes. SEE REVERSE FOR EXPLANATORY'LANGUAGE
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