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Home My Public Portal About5633 ROSEMEAD BLVD_Electrical__ WORKER'S COMPENSATION DECLARATION 766A6W DPW(12-91) . APPLICATION FOR ELECTRICAL PERMIT LJ I hereby affirm that I fiave a certificate of consent to self Insure, or a ce(.tificate of Worker's Compensation Insurance,or a certified COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS BUILDING AND SAFETY DIV. copy thereof(Sec.3800 Lab.C.) I ,4 OII O. V Company < ��t' ' l FOR APPLICANT TO FILL IN JOB -Certified copy Is hereby furnished. Now Residential Bldgs.&Pools NO. EACH FEE LOCALITY ❑ Ce tied copy Is filed with the cc my bul Ing Inspection 1 &2-Family,Sq.Ft. _ $ $ NEAREST JIF ep rtmen l i � Multi-family Sq.Ft. CROSS ST. Date ` Appllcan %• \ l Residential Swimming Pools ASSESSOR !' MAP BOOK PAGE PARCEL OWNCERTIFICATE OF EXEMPTION FR yvORKERS' Outlets:Rec._Light Sw. FIRM N OR COMPENSATION INSURq�E 9 FIRM NAME First 20 MAIL (This section need not be completed If th work Involve by the Total No. Additional ADDRESS permit Is for one hundred dollars($100)or less.) I certify that in the performance of the work for which this permit CITY Tel.No. is Issued, I shall not employ any person In any manner so as to PLAN CHECK become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 APPLICANT Total No. Additional ADDRESS Date Applicant RESIDENTIAL APPLIANCES NOT OVER 3 HP. NOTICE TO APPLICANT: If, after making this Certificate of CITY Tel.No. Exemption,you should become subject to the Workers'Compensation OTHER APPLIANCES NOT OVER 3 HP. (� provisions of the Labor Code, you must forthwith comply with such APPLICANT �l . j`L7 provisions or this permit shall be deemed revoked. Power Apparatus&Large Appliances LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS l C`1 I hereby affirm that I am licensed under provisions of Chapter 9 Over 3 to 10 Incl. CITY , �• Tel.No. t d` 7j (commencing with Section 7000)of Division 3 of the Business and '�, • (�� (� O ]� Professions Code,and my license is in full force and effect. Over 10 to 50 Incl. LICENSE ORClara' rs il_S Over 50 to 100 Incl. REG.NUMBER Over 100 DISTRICT NO. P SED BY O License Number LIc.Class Pep � Services,Swbd.,MCC&Panelboards G Contra" p Date \ r 0-399 Amp Under 600 V DATE ❑ I 400-1000 Amp.Under 600 V ��Z s '9 VALIDATION V I am a)Opt under S c. Over 1000 Amp.or Over 600 V FINAL L1J B.&P.C.for thi0. s reas BRANCH CIRCUIT FEES BY cli Date: 15A,or 20A,120V,Lighting or Recept. kA41 1 To 10 Branch Circuits Signature 11 To 40 Branch Circuits ❑ 41 Or More Branch Circuits Exemption for Reg.Maint.Elect. 15A,20A,208V To 277V Lighting Br.Circuits i SINGLE FAMILY Temp.Power Pole&Appurtenances ACCT. HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit ` � �) I hereby affirm that I am exempt from the Contractor's License Law c for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits Code): f ITEMS ❑ I,as owner of the property,will do the work and the structure Misc.Conduits&Conductors ''OTE lir 6 10 is not Intended or offered for sale(Section 7044, Business Other(See Complete Fee Schedule) and Professions Code). ® NECK 66.19 11 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the v performance of the work for which this permit is issued(Sec. 3097, PERMIT FEE (Sub-Total) G� Civ.C.) -aB1 2/22/91 PLAN CHECKING FEE Lender's Name 4'982 1 R! 6'10 PERMIT ISSUING FEE J Lender's Address I certify that I have read this application and under penalty of puqury state TOTAL FEE that the above information is correct. I agree to comply with all County ordinances and S is laws regulating Electrical wiring,and hereby authorize represen atives f his County to enter upon the above-mentioned property for inspe iq p ores. SEE REVERSE FOR EXPLANATORY LANGUAGE SIGNATURE OF PE f M EE I DATE WORKER'S COMPENSATION DECLARATION 76A663 DPW(t2 91) APPLICATION FOR ELECTRICAL PERMIT �J I hereby affirm that) hav8 a dertificate of consent to self insure, or aAyertificate•of Worker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES � DEPT.OF PUBLIC WORKS BUILDING AND SAFETY DIV. copy thereof(Sec.3800 Lab.C.) PolicyNO "' 5 COm an /, �`_n FOR APPLICANT TO FILL IN JOB .+ n Company NO. EACH FEE ADDRESS 011 Certified copy is hereby furnished. New Residential Bldgs.&Pools $ $ LOCALITY ❑ Certified copy Is filed with the county building Inspection 1 &2-Family,Sq.Ft. l^^ department. C a Multi-family Sq.Ft. CROSS ST. O/j � Y -7 Date X zApplicant ��r�� n�L�� Residential Swimming Pools ASSESMAP BOOK •� PAGE PARCEL OWNROR CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec._Light Sw. FIRMENAME �.J/�L✓i/ / COMPENSATION INSURANCE First 20 MAIL (This section need not be completed if the work Involved by the Total No. Additional ADDRESS permit is for one hundred dollars(5700)or less.) I certify that in the performance of the work for which this permit CITY ti� yr �f- T.I.No. is issued, I shall not employ any person in any manner so as to PLAN CHECK v - become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 APPLICANT J Total No. Additional ADDRESS Date L-:00"G/X-ApplicantU Cil RESIDENTIAL APPLIANCES NOT OVER 3 HP. ' NOTICE TO APPLICANT: If, after making this Certifica a of CITY 6,, T.I.No. ^ Exemption,you should become subject to the Workers'Compensation OTHER APPLIANCES NOT OVER 3 HP. provisions of the Labor Code,you must forthwith comply with such PERMITPower Apparatus&Large Appliances APPLICANT Sc provisions or this permit shall be deemed revoked. LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS Z I hereby affirm that I am licensed under provisions of Chapter 9 Over 3 to 10 Incl. �i (commencing with Section 7000)of Division 3 of the Business and CITY / r,`� Tel.No. Professions Code,and m license is in full force and effect. Over 10 to 50 Incl. } Y LICENSE OR Over 50 to 100 Incl. REG.NUMBER Class. 0- Over 100 DISTRICT NO. PROCESSED BY V License Number Lic.Class a — p Services,Swbd.,MCC&Panelboards ��-�O .�✓2��— "�� a: Q jjf 7� �v`�'.L FINAL 0-399 Amp.Under 600 V FINAL Contractor � Date DATE S V ❑ 400-1000 Amp.Under 600 V 'G�y`� VALIDATION ULI I am exempt under Sec. Over 1000 Amp.or Over 600 V FINAL f0_ B.&P.C.for this reason BRANCH CIRCUIT FEES BY 15A, Cl)Date: 15A,or 20A,120V,Lighting or Recap,. Z — 1 To 10 Branch Circuits �,'�v 1 Signature 11 To 40 Branch Circuits ❑ 41 Or More Branch Circuits ACIC 1T °n Exemption for Reg.Maint.Elect. 15A,20A,208V To 277V Lighting Br.Circuits 3303 252.20 SINGLE FAMILY Temp.Power Pole&Appurtenances HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit 1 1TENS I hereby affirm that I am exempt from the Contractor's License Law fqi s-J + for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits i�•{.-.L. 2: a Code): CASH CASH 232020 ❑ I,as owner of the property,will do the work and the structure Misc.Conduits&Conductors r IC` `�, is not intended or offered for sale(Section 7044, Business Other(See Complete Fee Schedule) ® '�t,-ti and Professions Code). CONSTRUCTION LENDING AGENCY ME,I'i ---131 2/20/96 1 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) Q 4924, j PP12:38 Civ.C.) PLAN CHECKING FEE Lender's Name PERMIT ISSUING FEE � J Lender's Address iJ Q 1 ✓Ly' I certify that I have read this application and under penalty of purjury state TOTAL FEE that the above information is correct. I agree to comply with all County ordinances and State laws reg ting Electrical wiring,and hereby authorize representatives f th' Dun' o enter upon the above-mentioned property for inspection urp s. SEE REVERSE FOR EXPLANATORY LANGUAGE / k__ I-— 2 e)1v SIGNATU EE DATE