HomeMy Public PortalAbout6022 ROSEMEAD BLVD_Electrical__ • WORKER'S I COMPENSATION DECLARATION 200019 DPW(12-87) APPLICATION FOR ELECTRICAL PERMIT
I'hergby affirm that have a certificate of consent to self insure, 76A663
or a certificate of Worker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS BUILDING AND SAFETY DIV.
copy thereof(Sec.3800 Lab.C.) Ly
❑ Y OV5 `Z P Y AD2Z LO
Polis Na. Company FOR APPLICANT TO FILL IN JOBDRESS
Certified copy is hereby furnished. New Residential Bldgs.&Pools H FEE LOCALITY
Sq.Ft. t
C
Certified copy is filed with the county building in Pe n 1 &2-Family, S _ $ Q $ NEAREST
department. Multi-family Sq.Ft. • CROSS ST. L
Date Applicant Residential Swimming Pools .ASSESSOR
MAP BOOK PAGE PARCEL
CERTIFICATE OF EXEMPTION FROMORKERS' OWNER OR /71
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Outlets:Rec._Light Sw. FIRM NAME (r yam{
COMPENSATION INSURANCE
First 20
(This section need not be completed If the work involved by the FAIL
No. Additional ADDRESS
permit Is for one hundred dollars($700)or less.)
I certify that in the performance of the work for which this permit CITY Tel.No.
is Issued, I shall not employ any person in any manner so as to PLAN
become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 APPLICANT
K
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.
of the Labor Code,you must forthwith comply with such APPLICANT -le -
provisions
provisions or this permit shall be deemed revoked.
Power Apparatus&Large Appliances Q O��
LICENSED CONTRACTORS DECLARATION Size&Type HGF„ICVA,�KVAR s �//� ADDRESS3
I hereby affirm that I am licensed under provisions of Chapter 9 S T Over 3 to 10 Incl. �' � b
(commencing with Section 7000)of Division 3 of the Business and CITYG f L LS Tel.No. Sjj 3�l
Professions Code,and my license is in full force and effect. Over 10 to 50 Incl.
LICENSEClass. � }
/+ Over 50 t0 100 Incl. REG.NUMBB ER 3 9 4 ('rJ-53
d
License Numb,r!�.� Lr IpX- Lic.Class G`` Over 100 DISTRICT NO. p P SED BY 0
rM97 r Ze `rr�. � Services,S d., C Panelboards
Cont clot C Date �^ Amp
-Ander 600 V FINAL 0
❑ DATE ` 7 J
mpt under Sec. 400-1000 Amp.Under 600 V �~Ze� -i 3
VALIDATION
I am exeV
Over 1000 Amp.or Over 600 V FINAL d
B.&P.C.for this reasonBRANCH CIRCUIT FEES BY
e: 15A,or 20A,120V,Lighting or Recept. Z_
1 To 10 Branch Circuits
Signature. 11 To 40 Branch Circuits
Al Or More Branch Circuits
M
Exemption for Reg. nt.Elect. 15A,20A,208V To 277V Lighting Br.Circuits
SINGLE FAMILY Temp.Power Pole&Appurtenances 2
HOME OWNER-BUILDER DECLARATION ith Ci
B
with One Branch Circuit I hereby affirm that I am exempt from the Contractor's License Law Sign wACCT■v
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits
Code): 33�� 7 790.30-
`Y
❑ I,as owner of the property,will do the work and the structure Misc.Conduits&Conductors 1 ITEMS
is not intended or offered for sale(Section 7044, Business they(See Complete Fee Sche le) 0 TOTAL 790.35
9 c 35
and Professions Code). L, 4J+
CONSTRUCTION LENDING AGENCY CHECK x90.35
1 hereby affirm that there is a.construction lending agency for the CHANGE ■JCI
performance of the work for which this permit is issued (Sec. 3087, PERMIT FEE (Sub-Total) (�
Civ.C.)
PLAN CHECKING FEE
Lender's Name 0000-0001 11/16/92
PERMIT ISSUING FEE O� 6,507 1 Aft 9:02
Lender's Address TOTAL FEE
I certify that I have read this application and under penalty of purjury state e).
that the above information is correct. 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
for
irk ction purpso . SEE REVERSE FOR EXPLANATORY LANGUAGE
7 -/G-P2
SIGNATURE OF P ITTEE DATE