HomeMy Public PortalAbout6162 ROSEMEAD BLVD_Electrical__ �:WORI RS'COMPENSATION DECLARAi;ON ,0,B
t6'self CE-806G 1 APPLICATION FOR ELECTRICAL PERMIT
' �H&.Y� a firm that I have a certificate of consent CE-806G
r` ingNrcj or a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
fir a Fertified copy thereof(Sec. 3800, Lab. C.) ``/
Policy No. 3 Company FOR APPLICANT TO FILL IN JOB
ADDRESS
Certified copy is hereby furnished. New Residential Bldgs. &Pools EACH NO. FEE
1 &2-Family, Ft. $ _ $ LOCALITY
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Certified copy is filed with the county building inspec- . S9•
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tion department. NEAREST
I Multi-family! . Ft. CROSS ST.
Residential Swimming Pools OWNER T.
Date Applicant OR
FIRM NAME
CERTIFICATE.OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw._ MAIL
COMPENSATION INSURANCE First 20 ADDRESS
(This section need not be completed if the work involved by Total No. Additional CITY Tel. No.
the permit is for one hundred dollars($100)or less.) PLAN CHECK
I certify that in the performance of the work for which this APPLICANT
permit is issued, I shall not employ any person' any m ner I
so as to become subject to the Wo rs'Co a satin S. Lighting Fixtures First 20 ADDRESS
Total No. Additional CITY Tel. No.
Date Applicon
NOTICE TO APPLI ANT: If, afterOking t is Certificate of Fixed Appliances Not Over 1 HP PERMIT
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Exemption, you should become subject to the Workers' Range_ Heater—D.W. — APPLICANT 11\C 4Z
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Compensation provisions of the Labor Code, you must forth- Oven —Dryer _W.M.— ADDRESS CJ. eJ
with comply with such provisions or this permit shall be Top FAU —W.H. —
deemed revoked. CITY Tel. rVo.60- .-�
-11
LICENSED CONTRACTORS DECLARATION Hood _ Fan _Other_ OYt
Disp. — Room Air Cond. LICENSE M Class.
I hereby affirm that I am licensed under provisions of Chapter 9 REG. NUMBER
(commencing with Section 7000)of Division 3 of the Business DISTRICT N PROCE BY
and Professions Code,and m license is in full force and effect. Power Apparatus&Large Appliances
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Size 8 Type HP, KW, KVA, or KVAR L
License Numb 4Lic. Class Up to 1 Incl. FINAL to
r� ,�c� Over 1 to 10 Incl. DATE VALIDATIO
Contractor Date I Over 10 to 50 Incl. CCC/// t-
❑ FINAL17
I am exempt under Sec. Over 50 to 100 Inc. BY
IL
Over 100
B.&P.C. for this reason
Services, Swbd., MCC&Panelboards
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
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License P-Additional Sign Branch Circuits 1 1 8 7 A
Law for the following reason (Section 7031.5, Business and
Professions Code): # 0 0 0 0 0 2
Misc. Conduits&Conductors
I, as owner of the property, will do the work and the I o - 62.38
structure is not intended or offered for sale (Section Other(See Complete Fee Schedule)-
7044, Business and Professions Code). 0 0062385
CONSTRUCTION LENDING AGENCY 1 203-84
i hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued PERMIT FEE (Sub-Total)
(Sec. 3097, Civ. C.).
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE
Lender's Address ¢
I certify that I have read this application and state that the TOTAL FEES$
above information is correct. I agree to comply with all County'
ordinances and State laws regulating Electrical wiring, and
her orize repre ntatives o is County to enter upon)
1 a -me ne dPert f spection purpcoses.10 SEE REVERSE FOR EXPLANATORY LANGUAGE
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Signature of Permittee Date