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Home My Public Portal About5122 ROSEMEAD BLVD_Electrical__ WORKERS'COMPENSATION DECLARATION CE-806G (2-80) CAPPLICATION FOR ELECTRICAL PERMIT CE-806 I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES (�2 BUILDING AND SAFETY insure, or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec. 3800,Lab. C.) FOR APPLICANT TO FILL IN JOB Policy No. Company NO. FEE ADDRESS New Residential Bldgs.&Pools EACH �� Certified copy is hereby furnished. 1 &2-Family,Sq. Ft. $ — $ LOCALITY ❑ Multi-family Sq. Ft. — NEAREST Certified copy is filed with the county building inspection CROSS ST department.' Residential Swimming Pools OWNER OR FIRM NAME Date Applicant Outlets: Rec._Light_Sw. MAIL S ADDRES �- f/ ai First 20 a°Lz CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. Additional CITY /--, Tel No. COMPENSATION INSURANCE PLAN CHECK } APPLICANT (L (This section need not be completed if the work involved Lighting Fixtures First 20 ADDRESS UO by the permit is for one hundred dollars ($100) or less.) Additional cc Total No. I certify that in the performance of the work for which this CITY Tel No. Q Fixed Appliances Not Over 1 HP (- permit is issued, I shall not employ any person in any manner PERMIT0 so as to become subject to the Workers' Compensation Laws. Range_ Heater_D.W. APPLICANT t/- Z (�'� IL /y /-/ 1 Oven _ Dryer_W.M._ ADDRESS f& VG_ CLCL Date/_2,ZJ�k �/Applicant �tb0/ f'?7, &fIIJ Top _ FAU _W.H.._ _ Hood — Fan —Other CITY � _ZCtd Tel No. NOTICE TO APPLICANT: If, after making this Certificate of Disp. — Room Air Cond._ LICENSE OR Exemption, you should become subject to the Workers' REG. NUMBER Class C- v Compensation provisions of the Labor Code, you must forth- Power Apparatus& Large Appliances DISTRICT NO. PRO SSE BY with* comply with such provisions or this permit shall be Size&Type HP,KW, KVA,or KVAR deemed revoked. L/ C� • Up to 1 Incl. FINAL Over 1 to 10 Incl. DATE LICENSED CONTRACTORS DECLARATION Over 10 to 50 Incl VALI DATION I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. BY AL 9 (commencing with Section 7000) of Division 3 of the Busi- Over 100 ness and Professions.Code, and my license is in full force and effect. Services /f License Number Lic.Class 0-200 Amp. Under 600 VjG`(G� 201-1000 Amp. Under 600 V Contractor Date Over 1000 Amp.or Over 600 V 02420 A • HOME OWNER-BUILDER DECLARATION Temp. Power Pole&Appurtenances •#-0 0'0 0 0 2 Sign with One Branch Circuit I hereby affirm that I am exempt from the Contractor's2.0'0 2 Q 5 0 License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): 0.0 - 20.5 0 c=., Misc.Conduits& Conductors F1 I, as owner of the property, will do the work and the Other(See Complete Fee Schedule)— 1222-8 1 structure is not intended or offered for sale (Section 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 PERMIT FEE (Sub-Total) 'issued (Sec. 3097,Civ.C.). Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee) Lender's Address PERMIT ISSUING FEE 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 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 Sign re of Permittee Date WORKERS'COMPENSATIONDECLARATION CE-806G (2-801 APPLICATION FOR ELECTRICAL PERMIT CE-806 I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES `�� BUILDING AND SAFETY insure, or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec. 3800,Lab.C.) FOR APPLICANT TO FILL IN JOB Policy No. Company EACH NO. FEE ADDRESS Z Z New Residential Bldgs.&Pools Certified copy is hereby furnished. 1 &2-Family,Sq. Ft. $ — $ S LOCALITY ❑ Multi-family Sq. Ft. — NEAREST Certified copy is filed with the county building inspection CROSS ST department. Residential Swimming Pools OWNER VA117-..s FIRM NAME Date Applicant Outlets: Rec.___�Light Sw. MAIL ADDRESS First 20 CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. Additional CITY `, A i Tel No. > COMPENSATION INSURANCEa PLAN CHECK 0 (This section need not be completed if the work involved APPLICANT U by the permit is for one huAdditional ndred dollars ($100) or less.) Lighting Fixtures First ADDRESS tr Additional Total No. 0CITY Tel No. I certify that in the performance of the work for which this Fixed Appliances Not Over 1 HP V permit is issued, I shall not employ any person in any manner PERMIT LU so as to become subject to the Workers' Compensation Laws. Range_ Heater_D.W. APPLICANT allC6>L� 0" c At / Oven _ Dryer_W.M.- ADDRESS — Z Dat h�a Applicant /t /�' �l' [�Vli1. Top _ FAU _W.H.. CITY Te No. I Hood _ Fan _Other_ �3` 7 NOTICE TO APPLICANT: If, after making this Certificate of Disp. — Room Air Cond._ LICENSE OR Exemption, you should become subject to the Workers' REG. NUMBER O crass Compensation provisions of the Labor Code, you must forth- Power Apparatus& Large Appliances DISTRICT NO. PROCE SED BY with comply with such provisions or this permit shall be ' Type deemed revoked. Size& HP,KW, KVA,or KVAR Up to 1 Incl. FINAL a . Over 1 to 10 Incl. DATE— l LICENSED CONTRACTORS DECLARATION Over 10 to 50 Incl. VALIDATION I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. FINAL v ,BY 9 (commencing with Section 7000)of Division 3 of the Busi- Over 100 ness and Professions.Code, and my license is in full force and effect. Services d � C_� 0-200 Amp:Under 600 V :3 AW � `3 3 4 2 A License Number Lic.Class �,, 201-1000 Amp. Under 600 V /(j, ��' # 0 0 0 0 0 2 C ntractor laI4��7: Date—3 �� Over 1000 Amp.or Over 600 V . 2'0 1 61.50 HOMEOWNER-BUILDER DECLARATION Temp.Power Pole&Appurtenances I hereby affirm that I am exempt from the Contractor's Sign with One Branch Circuit 0 C5 License Law for the following reason (Section 7031.5, Busi- Additional Sign Branch Circuits 0 3.25-82 ness and Professions Code): 3 . 9 0 A Misc.Conduits&Conductors �, El I, as owner of the property, will do the work and the Other(See Complete Fee Schedule)— structure is not intended or offered for sale (Section # o 0 0 2 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY 2 I hereby affirm that there is a construction lending agency O' for 'the performance of the work for which thisermit is D. 5 C issued (Sec. 3097,Civ.C.). p PERMIT FEE (Sub-Total) /5 3,; o•o Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee) 0 3.2 55. 82 Lender's Address PERMIT ISSUING FEE Cl 6-6 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 ordinances and State laws regulating Electrical wiring, and hereby authorize representatives of this County to enter upon the ab ve-mentioned property for inspection purposes. p SEE REVERSE FOR EXPLANATORY LANGUAGE 12-� O 2— Sig ture of Permittee Date WORKERS'COMPENSATION DECLARATION " CE-806G (2-80) APPLICATION FOR ELECTRICAL PERMIT CE'-806 I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY insure, or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec. 3800, Lab.C.) (.,(D 5 FOR APPLICANT TO FILL IN JOB s Policy NoG!y,1 Company --1��1�� , New Residential Bldgs.&Pools EACH NO. FEE ADDRESS [ Certified copy is hereby furnished. 1 &2-Family,Sq. Ft. $ — $ LOCALITY G Multi-family Sq. Ft. — NEAREST Certified copy is filed with the county building inspection CROSS ST departme t. Residential Swimming Pools OWNER OR �L�1 �� FIRM NAME C�4f Date �pplicantZki 4 Z �� Outlets: Rec._LigW 2 Sw. MAIL First 20 ADDRESS CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. Additional CITY Tel No. COMPENSATION INSURANCE PLAN CHECK d APPLICANT 0 (This section need not be completed if the work involved Lighting Fixtures First 20 0 by the permit is for one hundred dollars ($100) or less.) Additional ADDRESS tY Total No. I certify that.in the performance of the work for which this CITY Tel No. F- Fixed Appliances Not Over 1 HP permit is issued, I shall not employ any person in any mannerPERMIT W so as to become subject to the Workers' Compensation Laws. Range_ Heater_D.W. APPLICANT 7i - fV a Oven Dryer_W.M. ADDRESS Z Date Applicant Top FAU _W.H.. Hood Fan _Other_ CITY �e6Tel Pfo. NOTICE TO APPLICANT: If, after making this Certificate of Disp. — Room Air Cond.— LICENSE OR Exemption, you should become subject to the Workers' REG. NUMBER ' Sf Class Compensation provisions of the Labor Code, you must forth- Power Apparatus& Large Appliances DISTRICT NO. PROCESSED BY with comply with such provisions or this permit shall be Size&Type HP,KW, KVA,or KVAR deemed revoked. Up to 1 Incl. FINAL Over 1 to 10 Incl. DATE LICENSED CONTRACTORS DECLARATION VALIDATION Over 10 to-50 Incl. I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. FINAL 00 9 (commencing with Section 7000) of Division 3 of the Busi- Over 100 BY ness and Professions.Code, and my license is in full force and effect. Services License Number2(504s Lic.Class G"/O 0-200 Amp. Under 600 V J 201-1000 Amp. Under 600 V Contractor Date Over 1 000Amp.or Over 600 V HOME OWNER-BUILDER DECLARATION Temp.Power Pole&Appurtenances ;95708A I I hereby affirm that I am exempt from the Contractor's Sign with One Branch Circuit # 0 0 0 0 0 2 License Law for the following reason' (Section 7031.5, Busi Additional Sign Branch Circuits 20 38 50 Hess and.Professions Code): ` Misc.Conduits&Conductors I, as owner of the property, will do the work and the Other (See Complete Fee Schedule)— o 0 o 3 8,5 0 5) structure is not intended or offered for sale (Section 7044, Business and Professions Code). 0 8 1 8-82 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is PERMIT FEE (Sub-Total) issued(Sec. 3097,Civ.C.). Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee) Lender's Address PERMIT ISSUING FEE 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 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 Sign a of Permittee Date