HomeMy Public PortalAbout6037 ROSEMEAD BLVD_Electrical__ /!�-W0�2KERS'COMPENSATION DECLARATION 76A663 ,0,8, APPLICATION FOR ELECTRICAL PERMIT
o- hereby affirm that I have a certificate of consent to self CE-8066
insure, or a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified copy thereof(Sec. 3800, Lab. C.)
Policy No. Company FOR APPLICANT TO FILL IN JOB
Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADDRESS
❑ Certified copy is filed with the county building inspec 1 1 &2-Family, Sq. Ft. $ — $ LOCALITY '
tion department. Multi-family Sq. Ft. — NEAREST
Residential Swimming Pools CROSS ST.
JA 1AV
Date Applicant OWNER OR
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw._ MAIL
COMPENSATION INSURANCE ADDRESS
s section need not be completed if the work involved by. First 20
(Thitip Total No. Additional CITY Tel. No.
the permit is for one hundred dollars(;100)or less.)
I certify that in the performance of the work for which this! A PPLALICANTK
permit is issued, I shall not employ any person in any manner
so as to become subject to the War Compe s io Laws. Lighting Fixtures First 20 ' ADDRESS
Total No. Additional
CITY Tel. No.
Date r ppfican Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT v
Exemption, you should become subject to the Workers' Range_ Heater_D.W.
Compensation provisions of the Labor Code, you must forth- Oven —Dryer _W.M.— ADDRES
with comply with such provisions or this permit shall be Top _ FAU —W.H. —
deemed revoked. i Cl Tel. No.
LICENSED CONTRACTORS DECLARATION Hood _ Fan _Other_ 00Z 05: eizu
Disp. _ Room Air Cond. LICENSE OR Class.
I hereby affirm that I am licensed under provisions of Chapter 9 REG. NUMBER e-16
(commencing with Section 7000)of Division 3 of the BusinessDISTRICT NOSS
. PR D BY
and Professions Code,and my license is in full force and effect. Power Apparatus 8 Large Appliances �/� y.
Size&Type HP, KW, KVA, or KVAR V t► 0
License Number Lic. Class Up to 1 Incl. FINAL V
Over 1 to 10 Incl. DATE " ALIDATION 29
Contractor Date❑ Over 10 to 50 Incl. FINAL
I am exempt under Sec. Over 50 to 100 Inc. BY can
B.&P.C. for this reason Over 100 tii
Date: Servi bd., MCC&Panelboards
200 mp. Under 600 V 2 4 6 5 A
Signature Amp. Under 600 V
❑ I Over 1000 Amp. or Over 600 V
Exemption for Reg. Maint. Elect. # o o o 0 0 2
SINGLE FAMILY Temp. Power Pole&Appurtenances ) 0 0 2 5 O
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License Additional Sign Branch Circuits o 0 0
Law for the following reason (Section 7031.5, Business and g 2 5 5 Q 5
Professions Code):
❑ I, as owner of the property, will do the work and the Misc. Conduits&Conductors 07. 1 6-85
structure is not intended or offered for sale (Section I Other(See Complete Fee Schedule)_ .
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued I PERMIT FEE (Sub-Total)
(Sec. 3097, Civ. C.). '
PLAN CHECKING FEE
Lender's Name 'I
PERMIT ISSUING FEE (J
Lender's Address
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
ordina s and State laws regulating Electrical wiring, and
here out oAegr
of this County to enter upon
the ove minspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Date