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Home My Public Portal About5743 ROSEMEAD BLVD_Electrical__ WORKERS'COMPENSATION DECLARATION CE 8o6G 10/91 APPLICATION FOR ELECTRICAL 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(Sec43800,Lab.C.) ,971A om Policy No.c '� panySti FOR APPLICANT TO FILL IN ,JOB r ❑ Certified copy,is thereby furnished. EACH NO.. FEE ADDRESS "• New Residential Bldgs..&Pools LOCALITY ❑ Certified copy is filed with the county building inspection' 1. & 2-Family,Sq.Ft. $ — $ department. Multi-family Sq.Ft. — NEAREST CROSS ST. Date 9- Applicant dded Residential Swimming Pools FIRM NAME / CERTIFICATE OF EXEMPTION FROM WORKERS' I Outlets:Rec Light—Sw.— MAILADDRESS �3. COMPENSATION INSURANCE First 20 (This section need not.be.completed if the work involved by the n CITY Tel.No. Total No. �L Additional permit is for one hundred dollars($100)or less.) I PLAN CHECK T I certify that in the performance of the work for which this permit APPLICANT is issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS Total No. Additional CITY Tel.No. Date Applicant Fixed Appliances Not Over 1 HP PERMIT NOTICE TO 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_ OR I hereby affirm that I am licensed under provisions of Chapter 9 LICENSE Disp. — Room B Air Cond. REG.NUMBER Claw (commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license is in full force and effect. Power Apparatus&Large Appliances DISTRICT NO. PROCESS e Size&Type HP,KW,KVA,or KVAR 0(3 V License Number 0 Lie.Class Up to 1 Incl. FINAL {, n Z Over 1 to 10 Incl. DATE _ 60-1"5 VALIDATION 0 Contractor-10•� ij1�d ate /b'— Over 10 to 50 Incl. FU- FINAL ❑ I am exempt under Sec. Over 50 to 100 Inc.' BY n a' B.&P.C.for this reason Over 100 N Services,Swbd.,MCC&Panelboards Z Date: 0-200 Amp.Under 800 V R Signature 201 - 1000 Amp.Under 800 V ❑ Over 1000 Amp.or Over 800 V Exemption for Reg.Maint.Elect: SINGLE FAMILY Temp.Power Pole&Appurtenances 7 HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit I hereby affirm that I am exempt from the Contractor's License Law ACCT.u ' for the following reason(Section 7031.5,Business and Professions Additional Sign Branch Circuits Code): 3303 31.30 Misc.Conduits&Conductors 1 ITEC F-1 1,as owner of the property,.will do the work and the structure Other(See Complete Fee Schedule) _ T4T�L l .30 is not. intended or offered for sale (Section 7044, Business pop. Professions Code). CONSTRUCTION LENDING AGENCY I CASH 31.30 I hereby affirm that there is a construction lending agency for the CME .00 performance of the work for which this permit is issued(Sec.3097, PERMIT FEE (Sub Total) Civ.C.). PLAN CHECKING FEE 0000-0001 $/ 9/95 Lender's Name PERMIT ISSUING FEE 2-7 9 , 1753 1 AN 8IS37 Lender's Address 1 certify that I have read this application and state that the above TOTAL FEE 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 Properoses. SEEREVERSE FOR EXPLANATORY LANGUAGE S' 17 Signature of Permittee I Da I ORKERS'COMPENSATION DECLARATION Z6AM3 DPW 3/87 APPLICATION FOR ELECTRICAL' PERMIT w firm that I have a certificate of consent to self iana63 CE-8066 certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS od copy thereof(Sec. 3800, Lab. C.) p Policy No OZ `3Company �. X11• FOR APPLICANT TO FILL IN JOB � f}4.' � ❑Certified copy is he eby furnished. �— New Residential Bldgs. 8 Pools EACH NO. FEE ADDRESS A�Vew - $ ,_ s LOCALITY -e- Certified t'. copy is filed with the county building inspec- 1 &2-Family, Sq. Ft. NEAREST tion department. Multi-family Sq. Ft. CROSS ST. u fl Af pp 4AI Residential Swimming Pools OWNER OR Date A Iicant�gr�h�6— .1 T, y- FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw.- MAIL COMPENSATION INSURANCE ADDRESS This section need not be completed if the work involved b First 20 CITY R Tel. No. the permit is for one hundred dollars(;100)or less.) Y Total No. Additional I certify that in the performance of the work for which this PL4 N CHECKAgPLICANT h �� permit is issued, I shall not employ any person in any manner Lighting Fixtures First 20 A PLICAN so as to become subject to the Workers'Compensation Laws. _ Additional Date Applicant Total No. CI Y Tel. No. � NOTICE TO APPLICANT: If, after makingthis Certificate of Fixed Appliances Not Over 1 HP PERMIT PA&I-12 1A Exemption, you should become subject, to the WorkersRange— Heater—D.W. — AP,PLICATION.' 9 Compensation provisions of the Labor Code, you must forth- Oven — Dryer —W.M.— ADDRESS with comply with such provisions or this permit shall be Top — FAU —W.H. — deemed revoked. CIT1Y4St 9 Hay,4,tirTel. No. LICENSED CONTRACTORS DECLARATION Hood — Fan —Other— LICENSE OR 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. PROCE d and Professions Code,and my license is in full force and effect. i �y� �" Size&Type HP, KW, KVA, or KVAR 5_,09 / O License Number 64 Lic. Class T Up to 1 Incl. FINAL Over 1 to 10 Incl. DATE VALIDATION Contractor N Tull 41 f N5 Date } � ��9 O ❑ TAT Over 10 to 50 Incl. FINAL V I am exempt under Sec. Over 50 to 100 Inc. BY W BAP.C. for this reason Over 100 Services, Swbd., MCC&Panelboards Z Date: 0-200 Amp. Under 600 V ® ,' s ^i,: .z Signature 201 - 1000 Amp. Under 600 V E] Exemption 1000 Amp, or Over 600 V "'._ Exemption for Reg. Maint. Elect. �. • SINGLE FAMILY Temp. Power Pole&Appurtenances I , HOME OWNER-BUILDER DECSign - •- n with One Branch Circuit I hereby affirm that I am exempt from the Contractor's License g •"'r= c';; �c Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits I �' ��-�'• r.•;�. Professions Code): I t.- €;NGE ❑ I, as owner of the property, will do the work and the Misc. Conduits&Conductors i structure is not intended or offered for sale(Section 7044, Other(See Complete Fee Schedule)— -- Business and Professions Code). CONSTRUCTION LENDING AGENCY I_, ;-)- .;.� r. 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) (Sec. 3097, Civ. C.). PLAN CHECKING FEE Lender's Name PERMIT ISSUING FEE Lender's Address TOTAL FEE 1 certify that I have read this application and state that the a�7 above information is correct. I agree to comply with all County ` ordinances and State laws regulating Electrical wiring, and I j hereby.authorize representatives of this County to enter upon i the bove-mentioned_prtoperty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE 'W6'141 - I ®s Signature of Permittee Date WORKER'S COMPENSATION DECLARATION �sqg�DPW(12-91) APPLICATION FOR ELECTRICAL PERMIT I hereby affirrw that I have a certificate of consent to self insure, , ora 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.) Policy No s Z 2�C bompany FOR APPLICANT TO FILL IN JOB IIIJ L� Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE LOCALITY-r 191Q0_c,r ❑ Certified copy is filed with the county building 1 e 1 &2-Family,Sq.Ft. _ $ $ NEAREST department. Multi-family Sq.Ft. CROSS ST. 445 7ZIPA-) Date 8 fid^ Applicant Residential Swimming Pools MAP BOOK PAGE PARCEL CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER OR COMPENSATION INSURANCE Outlets:Rec.—Light Sw. FIRM NAME First 20 MAIL (This section need not be bompleted If the work Involved by the Total No. Additional ADDRESS permit Is for one hundred dollars(8100)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. PERMIT provisions of the Labor Code,you must forthwith comply with such power Apparatus&Large Appliances APPLICANT �j�' LJNL provisions or this permit shall be deemed revoked. LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS I hereby affirm that I am licensed under provisions of ChOver 3 to 10 Incl.apter 8 (commencing with Section 7000) of Division 3 of the Business and CITY N. O DJlo T.I.No. 6,?— Professions Code,and my license is in full force and effect. Over 10 to 50 Incl. LICENSE OR S - Over 50 to 100 Incl. REO.NUMBER Over s d License Number 1/ ✓ 2/r�Z11Lic.Class Over 100 DISTRICT NO. P�3ED BY V /t C Services,Swbd.,MCC&Panelboards i � Contractor r��`Date 8' 0^9� 0-389 Amp.Under 600 V FINAL Q DATE F1 I am exempt under Sec. 400-1000 Amp.Under 600 V VALIDATION W Over 1000 Amp.or Over 600 V FINAL D. B.&P.C.for this reason BRANCH CIRCUIT FEES BY N Date: 15A,or 20A,120V,Lighting or Recept. Z 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 J39W01TEMS 65.60 SINGLE FAMILY Temp.Power Pole&Appurtenanceso, ,)� HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit O TOTAL 1 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 Code): E 695%% F1 1,as owner of the property,will do the work and the structure Misc.Conduits&Conductors Gf15R is not intended or offered for sale(Section 7044, Business Other(See Complete Fee Schedule) , and Professions Code). ��0-pppi u/10r95 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the 1784 1 AN 9439 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 � O Lender's Address / r I certify that I have read this application and under penalty of purjury state TOTAL FEE 4-6 4o; that the above information is corTp J agree to comply with all County ordinances and State laws re lectrical wiring,and hereby authorize representatives of this o enter upon the above-mentioned property for inspe SEE REVERSE FOR EXPLANATORY LANGUAGE SIGNATURE OF PERMITTEE DATE