HomeMy Public PortalAbout6148 ROSEMEAD BLVD_Electrical__ WORKERS'COMPENSATION DECLARATION CE 8066 1p87 APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self.insure,
or a certificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof(Sec.3600,Lab.C.)
Policy No. Company FOR APPLICANT TO FILL IN JOB
❑ Certified copy is hereby furnished. New Residential Bldgs.&Pools EACH NO. FEE ADDRESS
❑ = LOCALITY
$ S
Certified copy is filed with the county building inspection 1 &2-Family,Sq.Ft.
department. Multi-family Sq.Ft.AB6 O NEAREST1
CROSS ST ,O/v � XAV �
Date Applicant Residential Swimming Pools OWNER OR
FIRM NAME , nn
CERTIFICATE OF EXEMPTION FROM WORKERS' MAIL
COMPENSATION INSURANCE Outlets:Ree-Light -Sw.- ADDRESS
(This section need not be completed if the work Involved by the First 20
permit is for one hundred dollars($100)or less.) Total No. Additional CITY y Tel.No. t?
PLAN
I certify that in the performance of the work for which this permit APPLICANT CHECK
is issued, I shall not employ any person in any manner so as to
become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS
p� Additional
/ Total No. CITY Tel.No.
Date O Applicant r~� Fixed Appliances Not Over 1 HP
NOTI E TO APPLICANT If, after makino this Certificate of PERMIT
Exemption,you should become subject to the Workers'Compensation Range_ Heater_ D.W. _ APPLICANT
provisions of the Labor Code,you must forthwith comply with such Oven _ Dryer_ W.M._ ADDRESSS.0,;
provisions or this permit shall be deemed revoked. Top _ FAU _ W.H.
CITY C Tel.No. _ y
LICENSED CONTRACTORS DECLARATION Hood _ Fan _ Other_
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. LICENSE OR Class. G ro
(commencing with Section 7000)of Division 3 of the Business and REG.NUMBER17
Professions Code,and my license is in full force and effect. Power Apparatus&Large Appliances DISTRICT NO PRO SED BY
+q7 Size&Type HP,KW,KVA,or KVAR C61 o 0
License Number 4t/,J 411 Lic.Class C' "� Up to 1 Incl. FINAL V
Over 1 to 10 Incl. DATE /„ /��j VALIDATION no
Contract00-4"/i�2 ',,g l��(' oOver 10 to 50 Incl. FIN0
❑ I am exempt under Sec. Over 50 to 100 Inc. BY AL �6�.0 W
BAP.C.for this reason Over 100 �/ N
Services,Swbd.,MCC&Panelboards ® Z
Date: 0-200 Amp.Under 600 V r'
Signature 201 - 1000 Amp.Under 600 V
❑ Over 1000 Amp.or Over 600 V
Exemption for Reg.Maint Elect.
SINGLE FAMILY Temp.Power Pole& Appurtenances i
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License Law
for the following reason(Section 7031.5,Business and Professions Additional Sign Branch Circuits
Code):
I
i
❑ I,as owner of the property,will do the work and the structure Misc.Conduits&Conductors TENS;
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) _ , --r TAL 247 4+0
r.f i
and Professions Code). NE'.1? '�7
4 ALL-11 2 o ,
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(Sec.3097, PERMIT FEE (Sub-Total)
Civ.C.).
Lender's Name �g
W*.AL W47 k' PLAN CHECKING FEE -3303-1; I�y 7/0-17/KPERMIT ISSUING FEE 18,511 1 ANIN•,;,1:
Lender's AddresS� '2� !/.�„�/_�Y�/ � �� A
1 certify that I have read this application and state that the above TOTAL FEE
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 inspection pur ses. SEE REVERSE FOR EXPLANATORY LANGUAGE
/ Sa
S nature mittee Date