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Home My Public Portal About5741 ROSEMEAD BLVD_Electrical__ WORKERS'COMPENSATION DECLARATION i 7&AMgoaw3ie� APPLICATION FOR ELECTRICAL PERMIT Q I hereby affirm that I have a certificate of consent to self 1.CE-806G ' insure, or a certificate of Workers'Compensation Insurance, I COUNTY OF LOS ANGELES j DEPT. OF PUBLIC WORKS or a certified copy thereof(Sec. 3800, Lob. C.) Policy No. /f Company j FOR APPLICANT TO FILL IN JOB y ❑Certified copy i h y furnished. I New Residential Bldgs. &Pools EACH NO: FEE ADDRESS ❑Certifi copy is filed with the county building inspec- I 1 &2-Family, Sq. Ft. $ _ $ LOCALITY NEAREST tion partm nt. Multi-family Sq. Ft. CROSS ST. . Date Applicant j Residential Swimming Pools OWNER OR FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:JZ _Sw.� MAIL COMPENSATION INSURANCE 2ec�—Light ADDRESS First 20 4— (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 CH K I certify that in the performance of the work for which this / APPLIC T permit is issued, I shall not employ any person in any manner , Lighting Fixtures First 20 �6 3 AD ESS p so as to become subject to the Workers'Compensation Laws. Additional 3p—�� /P ��. Total No. �� COY Tel. No. Date 1z Applicant �� I Fixed Appliances Not Over 1 HP NOTICE TO APPLICANT: If, after making this Certificate of PERMIT APPLICATION Exemption, you "should become-subject to the Workers' Range— Heater—D.W. — C�/EL Compensation provisions of the Labor Code, you must forth- I Oven — Dryer —W.M.— ADDRESS 7 with comply with such provisions or this permit shall be Top — FAU —W.H. — deemed revoked. CITYHood — Fan ss�dQ,�e9.v Tel. No�- —Other— LICENSED CONTRACTORS DECLARATION LICENSE Disp. — Room Air Cond. — 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 + Power Apparatus&Large Appliances DISTRICT NO._ PRO D BY >_ and Professions Code,and my license is in full force and effect. ..ee,� O - a- //'� J'�/� j Size&Type HP, KW, KVA, or KVAR �J , U(� O License Number Lic. Class4� Up to 1 Incl. FINAL U �. G'�2 /Z . �u_- I Over 1 to 10 Incl. DATE �. �. VALIDATION Contract r Date �� O Over 10 to 50 Incl. i— FINAL U I am exempt under Sec. Over 50 to 100 Inc. �BY LIJ B.&P.C. for this reason Over 100 CL Services,Swbd., MCC&Ponelboards Date: '~30—�/ ® Z j 0-200 Amp. Under 600 V j Signature 201 - 1000 Amp. Under 600 V ❑ j Exemption for%Reg. Mdint. Elect. Over 1000 Amp, or Over 600 V SINGLE FAMILY Temp. Power Pole&Appurtenances j HOME OWNER-BUILDER DECLARATION '^ Sign with One Branch Circuit I hereby affirm that I am exempt from the Contractor's License gr;: t _F Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits Professions 0.3 Conduits&Conductors❑ s I, as owner of the property, will do the work and the Misc. � r IS structure is not intended or offered for sale(Section 7044, Other(See Complete Fee Schedule)_ .ate_' R Business and Professions Code). VOTAL, {:• ems^?,:tt CONSTRUCTION LENDING AGENCY (I 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) •`*"=tit�G �1=1-•' (Sec. 3097, Civ. C.). PLAN CHECKING FEE Lender's Name 1, PERMIT ISSUING FEE Ll:lHl�l"Ll_l:l ).,.% ' � S 1�:�_�Flry 1 P 3'•',3 1:#_ Lender's Address 3 I certify that I havke ead t ion and state that the TOTAL FEE above information ect. I agree t comply with all County ; ordinances and t laws regu ng Electrical wiring, and I hereby auth a repre sof this County to enter upon , the abov ntio roses. SEE REVERSE FOR EXPLANATORY LANGUAGE i .,S' nature o ermittee Date WORKERS'COMPENSATION DECLARATION l CE-606G ic/St APPUC=ON OR EL1�E�TRICAL PERMIT I hereby affirm that I have a certificate of consent to self Insure, or a certificate of Workers'Compensation Insurance, or,a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY copy thereof.(Seer 3800,Lab.C.)• Policy No. Company ` FOR APPLICANT TO FILL IN JOB❑ �rf Certified copy is hereby furnished. I New Residential Bldgs.&Pools EACH• NO. FEE ADDRESS 1 &2-Family,Sq.Ft. $ — $ LOCALITY Certified copy is filed with the county building inspection NEAREST department. Multi-family Sq.Ft. — ST Residential Swimming Pools CROSS O Date Applicant OWNER.ORor FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' OutletsRec Light_Sw. MAIL : — —. COMPENSATION INSURANCE � ADDRESS 0i, ImAi ' (This section need not'be,completed if the work involved by the First 20 CITY Tel.No permit is for one hundred dollars($100)or less.) Total No. Additional I certify that in the performance of the work for which this permit PLAN CHECK APPLICANT is issued, I shall riot employ any person n any manner so as to become subject o th Workere`'Co naafi Laws. Lighting Fixtures First 20 ADDRESS (' Additional Total No. CITY Tel.No. Date �� Applica Fixed Appliances Not Over 1 HP PERMIT NOTICE AO APPLICANT: If, after making this Certificate of APPLICANT Exemption,you should become subject,to the Workers'Compensation Range_ Heater_ D.W. provisions of the Labor Code,you must forthwith comply,with such Oven _ Dryer_ W.M._ ADDRESS provisions or this permit shall be deemed revoked. , Top — FAU _ W.H. CITY Tel.No. LICENSED CONTRACTORS DECLARATION Hood _ Fan Other_. I hereby affirm that I am licensed under provisions of Chapter'9 1LICENSE OR Disp. — Room Air Cond. REG.NUMBER ('j Clas (commencing with Section 7000)of,Division 3 of the Business and Professions Code,and my license is.in full force and effect. DISTRICT O. PROCESSED BY Power Apparatus&Large Appliances �� ' j Size&Type HP,KW,KVA,or KVAR , License Number Lic.Class Up to 1 Incl. FINAL Over 1 to 10 Incl. DATE � ` j ��f �A (/J VALIDATION Contra ' Date Over 10 to 50 Incl. FINAL r•' O 0, I am exempt under Sec. v Over 50 to 100 Inc. BY .,,�. a W j Over 100 B.&P.C.for this reasonSe w"?-f ;°• rvices,Swbd.,MCC&Panelboards _ I, Z Date:' 0-200 Amp.Under 600 V Signature ! 201 - 1000 Amp..Under 6.00 V ❑ Over 1000 Am or Over 600 V "I Exemption for Reg.Mil int,Elect: p r_I)H_ SINGLE FAMILY Temp.Power Pole&Appurtenances HOME OWNER-BUILDER DECLARATIONSign with One Branch Circuit ^ tir I hereby affirm that I am exempt from the Contractor"s License Law for the following reason(Section 7031.5,Business and Professions Additional Sign Branch Circuits ; Codes _ _ i r;,•, r,'•-, Misc.Conduits&Conductors El I,as owner of the property,.will do the work and the structure + ��; :' is not intended or offered for sale (Section 7044,•Business Other(See Complete Fee Schedule) _ .j i?_, ,. L"['s It°•=' 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.issued(Sec.3097, PERMIT FEE (Sub-Total) Civ,C.). PLAN CHECKING FEE Lender's Name 1 PERMIT ISSUING FEE _ Lender's Address I certify that I have read this application and state that the above TOTAL FEE. information is correct.1 agree to comply with all County ordinances } and State laws regulating Electrical wiring, and hereby authorize L repre RI've of this Cou Py enter upon the above-mentioned r P perty or pe ti n p SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date , 1