The URL can be used to link to this page

Home My Public Portal About5729 ROSEMEAD BLVD_Electrical__ j WORKER'S COMPENSATION DECLARATION 9 DPW 8/89 APPLICATION FOR ELECTRICAL PERMIT 78ABB I her by affirm that I have a certificate of consent.to self Insure, 7BA66S or certificate of,Wofker's,Compensation Insurance,or a certified COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS BUILDING AND SAFETY DIV. copy thereof'(Sec.3800 Lab.C.). P❑OIIOy NO. Company _ .�. FOR APPLICANT TO FILL IN JOB . lip 01 Certified copy is hereby fumished• New Residential Bldgs.&Pools EACH NO. FEE $ _ $ LOCALITY / ❑ Certified copy.Is filed with the cdunty building Inspection 1&2-Family,Sq.Ft. _ NEAREST. department. Multi=family Sq.Ft. CROSS ST.' Date Applicant Residential Swimming Pools ASSESSOR 1 MAP BOOK, PAGE PARCEL CERTIFICATE OF EXEMPTION FROM WORKERS` Outlets:Rec._Light Sw. F�NAME COMPENSATION INSURANCE (This section need not be completed If the work Involved by the First 20 MAIL permit is for one hundred dollars($.100)or less:) Tota No. Additional ADDRESS C? I certify that In the performance of the work for which this permit CITY Tel:No. Is'issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws. LlghtinglFixtures. First 20 APPLICANT K Total No. Additional. " _ ADDRESS: Date —1 Applicant 15 R 20A,120V BRANCH CIRCUITS NOTICE TO P (CANT: If,. after mak g t Certificate. of CITY i TeL No. Exemption,you should become subject to W ra'Compensation 1 TO 10 INCLUSIVE EACH provisions of the Labor Code,you must forthwiffi comply with such 11 TO 40 INCLUSIVE EACH 'PERMIT provisions at this,permit shall be deemed revoked. APPLICANT J 41 OR MORE BRANCH.CIRCUITS LICENSED.CONTRACTORS DECLARATION' ' ADDRESSa I.,hereby affirm that I am licensed:under provisions•of Chapter 9 15 OR 20A,208V TO 277V LIGHTING EACH - (commencing with Section 7000)of Division 3..of the Business and i - CITY Tel.No._44-$ CJ Professions Code;and my license•Is In full force and effect. RESIDENTIAL APPLIANCES UP TO 3HP LICENSE ort' ,y, e Power Apparatus&Large Appliances REG:NUMBER ID @ 5 0, Claw. G�y C License Number.. �!o�n Lic.Class ? Size&Type HP,KW,KVA,or KVAR DISTRICT NO. PROCESSED BY F. Up to 3 Incl. Liz 0. Contractor Date e: (� Ove'3 to 10 InDATE O7 ❑ Over10t.50Incl cc I am exempt under Sec. I Over 50'to 100 Incl. VALIDATION FINAL B.&P:C.'for this reason Over 100 BY Services,Swbd.,MCC&'Panelboards Date: 0.'-200-Amp.Under 600 V Signature 2011-1000 Amp.Under'600 V ❑ Over 1000 Amp.or Over 600 V " Exemption for Reg.Maint.Elect. SINGLE FAMILYTemp.Power Pole&Appurtenances I "' ° HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit '", `-<`.• r.!'•.' I hereby affirm:that I am exempt from the Contractor's License Law for the following reason(Section 7031.5, Business and Professions Additlonal Sign Branch Circuits »••�- Code): w! 1,as owner of the.property,will do the work-and the structure Misc.Conduits&Conductors Is not Intended or offered for sale(Section 7044, Business Other(See Complete Fee Schedule) ® , :F ��5 s•. and Professions,Code). I •� -- CONSTRUCTION LENDING AGENCY - Z" I 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) CIV.C'.) PLAN!CHECKING FEE Lender's Name -'-`• - " t°'°y' PERMIT ISSUING FEE p� Lender's Address TOTAL FEE' I certify that I have read this application and state that the above information is correct.. I agree to comply with all County ordinances i and State laws regulating Electrical wiring,and hereby authorize representatives of'this,County to enter upon the above-mentioned Property for inspection ureases. SEE REVERSE FOR EXPLANATORY LANGUAGE (I SIGNATURE OF 'PPCANYDRAGENT DATE I + 4 ION ,. WO RKER'S.COMPENSATate of consent to 2oaol�eDPW9/88 APPLICATION FOWE'LE'CTRICAL PERMIT u I hereby affirm that I have a certificate of consent to self insure, or a certificate 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.) ((AA��yy//�lvvl"" ,(` //�� Policy No.f 9 Company�/A P� _ZLq r' l/ � FOR APPLICANT i0 FILL IN JOB ADDRESB ❑ Certified copy Is.herebyfurnished. New Residential Bldgs.&Pools EACH :NO. FEE LOCALITY ❑ 1&2-Family,Sq.Ft. $ $ Certified copy is filed with the coup buildi g inspe Ion NEAREST I� department. Multi-family Sq.Ft. CROSS ST. jt1 plti ' Date LE21L y Applicant y Residential Swimming Pools ASSESSOR MAP BOOK CERTIFICATE OF EXEMPTION FROM WORKERS' 14 OWNER OR PAGE PARDFI COMPENSATION INSURANCE Outlets:Rec. Light Sw.. `70 FIRM NAME �rJA �� d� 2 First 20 / MAIL (This section need not be completed if the work involved by the Total No. Additional 0 O ADDRESS '�A I permit Is for one hundred dollars($100)or less.) I certify that in the performance of the work for which this permit CITY • * .u*Y T.I.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 '15 OR 20A,120V BRANCH CIRCUITS NOTICE TO APPLICANT: 11,.after .making this Certificate of CITY Tel.No. I Exemption,you should become subject to the Workers'Compensation 1 TO 10 INCLUSIVE EACH provisions of the Labor Code, you must forthwith comply with such 11 TO 40 INCLUSIVE EACH PERMI pM lL) �� . provisions or this,permit shall be deemed revoked. 41 OR MORE BRANCH CIRCUITS EACH 3/1- �I� 1M1 ,„1 uq >. LICENSED CONTRACTORS DECLARATION ADDRESS vis 1 W 4 I -1 0- I hereby affirm that I am licensed under provisions of Chapter 9 15 OR 20A,208V TO 277V LIGHTING EACH O (commencing with Section'7000)of Division 3 of the Business �and CITY Ar' n jpj 64 ,Tel..No. ItY-7)��a � Professions Code,and my license is in full force and effect. RESIDENTIAL APPLIANCES UP TO SHP LICENSE OR Q Power Apparatus,&Large Appliances REG.NUMBER ��' 0 License Number �r( "S Lic.Class Size&Type HP,KW,KVA,or KVAR DISTRICT NO. y PROC SED BY V Up to 3 Incl. •�D W LG �� -Z _ Z Over 3 to 10 Incl. FINALNco Contracts_ Date Over 10 to 50 Incl. Z ❑ I am exempt under Sec. Over50 to 100 Incl. J Z A Z, VALIDATION B.&P.C.forason FINAL Over 100 BY -y+,Q Services,Swbd.,MCC&Panelboards. Date: 0-200 Amp.Under 600 V SignatureV_A 201-1000 Amp.Under 600 V ❑ Over 1000 Amp.or Over 600 V - Exemption for Reg.Maint.Elect. SINGLE FAMILY Temp.Power Pole&Appurtenances ••-• HOME OWNER-BUILDER DECLARATION I hereby affirm that I am.exempt from the Contractor's License Law Sign with One Branch Circuit for the following reason(Section 7031.5, Business and Professions Additional Sign Branch Circuits ;•,�/ C.—- Code): 1,as owner of the property,will do the work and the structure Misc.Conduits&Conductors i= ?•." is not intended or offered for sale(Section 7044, Business 'Other(See Complete Fee Schedule) _r and Professions Code). , I~I'i�I..•i 1 �3s u S.i� CONSTRUCTION LENDING AGENCY V ". •` F, I 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) Civ.C.) PLAN CHECKING FEE Lender's Name - PERMIT ISSUING FEE !f I '• :;=4e Lender's Address FEE q I'certify that I have read this application and state that the above TOTAL �p pr s information Is correct. I agree to comply with all County ordinances and State'laws regulating Electrical wiring, and hereby authorize re tatives of this County to enter upon the above-mentioned prd Vert �PLcA.TOR s. SEE REVERSE FOR EXPLANATORY LANGUAGE sl DATE