HomeMy Public PortalAbout6152 ROSEMEAD BLVD_Electrical__ WORKERS'COMPENSATION DECLARATION 78A8 10/61
Cl`80606G APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of Consent to sslf insure,
or a certificate of Workers' Corvpensation.lnsurance,or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof(Sec.3800,Lab.C.)
Policy No. Company FOR APPLICANT TO FILL IN JOB
ADDRESS ff
❑ Certified copy is hereby furnished. New Residential Bldgs.&Pools EACH NO. FEE
LOCALITY
❑ Certified copy is filed with the county budding inspection 1 & 2-Family,Sq.Ft. $ _ $ E
department. Multi-family Sq.Ft. � ti 21Z_0 41 Al) NEAREST l ) M
CROSS ST L�"•,V�
Date Applicant Residential Swimming Pools OWNER OR //
FIRM NAME ZZ P AL
rL� ,
CERTIFICATE OF EXEMPTNSATION INSURANCE NFOM WORKERS' Outlets:Rec—Light_Sw.— DDRESSZ7 y/_ CF 6� 0 ,
COMP(This section need not be completed if the work involved by the First 20 CITY r4 P
PLAN CHECK Tel.No.
permit is for one hundred dollars($100)or less.) Total No. Additional .;;K O
I certify that in the performance of the work for which this permit APPLICANT
is issued, I shall not emp!oy any person in any manner so as to
become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS
Additional
Ij`/1 PG1 C Total No. CITY Tel.No.
Date / / Applicant Fixed Appliances Not Over 1 HPPERMIT ��, �
NOTICE TO APPLICANT: If, after maAg this Certificate of APPUCAN / C- ,07j C/27 C
Exemption,you should become subject to the Workers'Compensation Range_ Heater D.W.
provisions of the Labor Code,you must forthwith comply with such Oven _ Dryer_ W.M._ ADDRESS/)-R
provisions or this permit shall be deemed revoked. Top — FAU _ W.H. _ CITY ClTel.Noy —
LICENSED CONTRACTORS DECLARATION Hood — Fan _ Other_
OR
1 hereby affirm that I am licensed under provisions of Chapter 9 LICENSE
(commencing with Section 7000)of Division 3 of the Business and Disp. — Room Air Cond. REG.NUMBER ER
Professions Code,and my license is in full force and effect. Power Apparatus&Large Appliances DISTRICT NO. PRO SSED >'
Size&Type HP,KW,KVA,or KVAR e O
License NumbersZ.,Y669 Lic.Class L Up to 1 Incl. FINAL U
_ DATE �A- � VALIDATION X
.�, . �CNTa ' J Over 1 to 10 Incl. (.y
Contrector� / t�� �7/ �•
� Over 10 to 50 Incl. FINAL 0
❑ I am exempt under Sale�)" Over 50 to 100 Inc. BY
G Over 100
BAP.C.for this reason
Services,Swbd.,MCC&Panelboards ® z
Date: 0-200 Amp.Under 600 V `—'
Signature 201 - 1000 Amp.Under 600 V
❑ Exemption for Reg.Maint.Elect. Over 1000 Amp.or Over 600 V
SINGLE FAMILY Temp.Power Pole&Appurtenances -e
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit `
I hereby affirm that I am exempt from the Contractor's License Law -r u
for the following reason(Section 7031.5,Business and Professions Additional Sign Branch Circuits Pik CT04
Code): 7'?f�� '��Y�0 4.
,�:�_
Mise.Conduits&Conductors❑ ITE
I,as owner of the property,will do the work and the structure 1 ITE G
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule)
and Professions Code). TOTAL 747 o tea-L0
CONSTRUCTION LENDING AGENCY CEECIA 247.40
1 hereby affirm that there is a construction lending agency for the r-
4
Performance of the work for which this permit is issued(Sec.3097, PERMIT FEE (Sub-Total)
Civ.C.).
F� 4 JM� // PLAN CHECKING FEE _
Lender's Name � d'C__ P� 7�i��+�('
`�. ']� PERMIT ISSUING FEE /
Lender's Address/�o_�, }(��•_ �� 1&52 1 AMD"?a.
I 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 purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
b
S" 1 of Permitt� ate