HomeMy Public PortalAbout6029 ROSEMEAD BLVD_Electrical__ WORKER S'COMP.ENSATIONDECLARATION 76A663 APPLICATION FOR ELECTRICAL PERMIT
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I hereby affirm that I have a certificate of consent to self i COUNTY OF LOS ANGELES BUILDING AND SAFETY
insure,or a certificate of Workers'Compensation Insurance;or �
a certified copy thereof(Sec.3800,Lab.C.) r
LTFOR APPLICANT TO FILL IN JOB L
Policy No �� Company � � kw'14 New Residential Bldgs.&Pools EACH NO. FEE ADDRESS 602 RoBemead;Blvdo
Certified copy is hereby furnished. 1 &2-Family,Sq.Ft. $ — $ LOCALITY
l Multi-family Sq. Ft. NEAREST
Certified copy is filed with the county building inspection CROSS ST
Claribala
department. /r� ,nr/ Residential Swimming Pools OWNER OR
Applicant `A 4V I I l0 ���� 1 FIRM NAME T
Outlets: Rec�Light First
1 ADDRESS t AV8
' - IL
First 20
CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. AdditionalCITY Tel No. �,
COMPENSATION INSURANCE PLAN CHECK n.
- APPLICANT
(This section need not be completed if the work involved Lighting Fixtures' First 20 V
by the permit is for one hundred dollars ($100) or less.) ADDRESS
TAdditional
Total No: I'
I certify that in the performance of the work for which This, Fixed Appliances Not Over 1 HP CITY Tel No.
pernift.'is issued, I shall not employ any person in any manner PERMIT
so as to become'subject to the Workers'Compensation Laws. Range_Heater D.W._ APPLICANT. OW.
Oven _ Dryer_W.M._ ADDRESS to
Date Applicant Top _ FAU _W.H.,_. 8843 ion Dr
Hood _ Fan. —Other CITY Ripsemead Tel'No280..42W .
NOTICE TO APPLICANT:.If, after making this Certificate of Disp. _Room Air Condom LICENSE OR
Exemption, you should become subject to the Workers' REG.NUMBER 297962 ClassQ-10
Compensation provisions of the Labor Code, you must forth- Power Apparatus&Large Appliances DISTRICT NO. PROCESSED BY
with comply with such provisions or this permit shall be' KW
HP
&T
Size Type , ,kVA,or
deemed revoked. SiKVAR �j d
i Up to 1 Incl. FINAL f
Over 1 to 7DATE VALIDATION0 Incl. l 2_�. )
LICENSED CONTRACTORS DECLARATION Over 10 to 50 Incl.
I hereby affirm that I am licensed under provisions of Chapter j Over 50 to.100 Inc. FINAL C%
9 (commencing with Section 7000)of Division 3 of the Busi- ( Over 100 BY
ness.and Professions.Code,,and my license Is in full force and
effect. Services _
License Number Z� 6 ic.Class C--�0 0 200 Amp.Under 600 V ` A+
201-1000 Amp.Under 600 V /, 2
Contractor ate ��`« Over 1000 Amp,or Over 600 V lb'
HOME OWNER-BUILDER DECLARATION Temp.Power Pole&Appurtenances
I hereby affirm .that I' am exempt from the,Contractor's' Sign with One Branch Circuit
License Law for the following reason (Section 7031.5, Busi- Additional Sign Branch Circuits
ness and Professions Code):
Misc.Conduits&Conductors
ElI, as owner of the property, will do•thework and the Other(See Complete Fee Schedule)— I• ;_9 2 2 9 Z A
structure Is not intended or offered for sale (Section
7044,Business and Professions Code). ## o o•o o a 2
CONSTRUCTION LENDING AGENCY '
I hereby .affirm that there is a construction lending agency 2 o -23,50
for the performance of the work for which this permit is
issued(Sec.3097,Civ.C.). PERMIT FEE (Sub=Total) 0,0 - 23,505
Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee)
12, 14-81 2, 4_$
Lender's Address PERMIT ISSUING FEE
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., ^ r
ordinances and State Is Ws regulating Electrical wiring, and, o�c3 r ,
hereby authorize represe fatives of this.0ounty to enter upon
the ab . - entioned pr erty for s tion p poses. I
,�yA�j /] SEE'REVE.RSE FOR EXPLANATORY LANGUAGE +.
Signature of Permittee Date L