HomeMy Public PortalAbout6235 ROSEMEAD BLVD_Electrical__ WORKERS'COMPENSAicat6 of
76-663 10,81 [a r�rP CATI®N FOR ELECTRICAL PERMIT {�
I hen•byraffirdn that I have'a.certificatL of cons%'nt to self In;;ure, c;E-aosG b'�I�C�"L� u I� u
.or a cediflcate of Workers',Compenslation Insurirtca, or a•ccrtifwd COUNTY OF LOS ANGELES BUILDING AND SAFETY
bopyfthereof(Sec.3800,Lab C.)
Policy No. Company FOR APPLICANT TO FILL IN JOB oe
+
❑ Certified copy is hereby furnished. New Res dcntial Bldgs. &Pools EACH NO FEE ADDRESS l� �if}GiE�r'Jy�e7i 4 v
❑ — LOCALITY'; 7
Certified copy is filed with the county bud . eding inspection 1 &2-Family Sq Ft
$ — S >� r/! )
NEARESdepartment. Multi-family Sq Ft d,-3 CROSS TT G'✓iL'("-"I -f
Date Applicant Remd;:ntial Swimming Pools OWNER OR
)Gj 10y� FIRM NAME I'��/� ✓�-"Y� r y�C ��
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec-G1 Lryht�S, (� IS
COMPENSATION INSURANCE
First 20 ADDRESS
(This section need not be completed if the work involved by theTotal No i. Additional �' 3 CITY j!J 7, �' Tel.No. - bJt�,ijJ
permit Is for one hundred dollars($100)or less.)
PLAN CHECK
I certify that in the performance of the cork for which th a permit APPLICANT
is Issued, I shall not employ any person in/any Itn{r so as to
become subject to the Workers Compens !on bq = Vv
Lighting Fixtures First 20 '� ADDRESS
+, f 15 Additional
G �t,� : `, Total No � CITY Tel.No.
Date Applicant / Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, after making this Ccrtrficato of APPLICANT
Exemption,you should become subject to tho V1.1orkors'Compensation Range_ Heater DW _
provisions of the Labor Code,you must forthv.ith comply with such Overt Drycr W M _ ADDRESS v�.
provisions or this permit shall be deemod revakod. Top '' FAU W.H _ j
LICENSED CONTRACTORS DECLARATION Hood — Fan Other_ CITY L Tel.No.
I hereby affirm that I am licensed under provis,ons of Chapter 9 Disp. Room Air Cond. LICENSE OR Class
(commencing with Section 7000)of Division 3 of the Business and REG NUMBER
Professions Code,and my license is in full force and effectDISTRICT NO. PROCESSED e
Powcr Apparatus&Large Appliances g
Size&Typo HP,KW KVA,or KVAR _7 a
Licenso Number Lic.Class Up to 1 Incl. FINALo
C1
Over 1 io 10 Incl. DATE 0.'
VALIDATION
Contrrictor Date Uva- 10 to 50 Incl U
❑ FINAL
I am exempt under Sec. Ovrr 5C to 100 Inc. BY W
—Ou.•r 100 �
BAP.C.for this reason to
Services Sv bd,MCC t'.Panciboards Z
Date. 0-200 Amp Under 600 V
Signature 201 - 1000 Amp.Und::r 600 V
❑ Ovar 1000 Amp.or Over 600 V
Exemption for Reg.Maint.Elect.
SINGLE FAMILY Temp Po.�cr Pole&Appurten.tnccs
HOME OWNER-BUILDER DECLARATION Sign with Ono Branch Circuit
I hereby affirm that I am exempt from the Contractors Licunse Law
Additional Sign Branch Circuits
for tho following reason(Section 7031.5,Businass and Profcss-ons
Code).
❑ I,as owner of the property,will do the Nark and the structure Misc.Conduits&Conductors+^
is not intended or offered for sale (Ssction 7044, Busineas Othar(Se:Cc rnplote Fc.: Schrdula:)
and Professions Code).
CONSTRUCTION LENDING AGENCY -"
I hereby affirm that there is a construction lend+nq agency for the
performance of the work for which this permit is issued(Sec 3097, PERMIT FEE (Sub-Total)
Civ.C.).
PLAN CHECKING FEE
Lend:—:Name
PERMIT ISSUING FEE
Lenders Address
I et;rtify that I have read this application and st.to that the above TOTAL FEE 5 J.2 S
information is correct.I agree to comply with ail County ordlnancos
and State lawsAregulating Electrical wiring, and hereby authorize
represantatives tf th ounty to enter upon tre above-mentioned
property for i�1 rpo G!-E REVERSE FOR EXPLANATORY LANGUAGE
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