The URL can be used to link to this page

Home My Public Portal About5753 ROSEMEAD BLVD_Electrical__ . WORKERS'COMPENSATION DECLARATION I 20.0019 DPW 3/87 /APPLICATION FOR ELECTRICAL PERMIT O I hereby affirm that I have a certificate of consent to self ';CE-806G insure, or a certificate of Workers'Compensation Insurance, i COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS or a certified copy thereof (Sec. 3800, La�C.) Policy No _-10157 Company FOR APPLICANT TO FILL IN JOB ❑Certified co is hereby furnished. - �- EACH NO. FEE ,ADDRESS PY Y New Residential Bldgs. 8 Pools $ LOCALI 1 s �rtified copy is.filed with the county building inspec- 1 &2-Family, Sq. Ft. — tion department. Multi-family Sq. Ft. NEAREST CROSS ST. ✓Date jt 1t-/CPP licant Residential Swimming Pools OWNER OR /..6% FIRM NAME G;s�i �`"'•� ��- CERTIFICATE OF EXEMPTIQZ7FROM WORKERS' i Outlets: Rec Light Sw._ 'MAIL COMPENSATION INSURANCE .ADDRESS his section need not be completed if the work Involved b i First 20 Total No. Additional CITY Tel. No. the permit is for one hundred dollars(;100)or less.) Y PLAN CHECK I certify that in the performance of the work for which this t -APPLICANT permit is issued,I shall not employ any person in any manner Lighting Fixtures First 20 jADDRE$S so as to become subject to the Workers'Compensation Laws. g g , ' Additional Date Applicant Total No. CITY Tel. No. NOTICE TO APPLICANT: If, after making this Certificate of Fixed Appliances Not Over 1 HP PERMIT Q Exemption, you should become. subject to the Workers' Range— Heater—D.W. — PPLICATION,(/ Al Compensation provisions of the Labor Code, you must forth- Oven — Dryer —W.M.— ADDRESS frG6/ OAUCLQR dUe with comply with such provisions or this permit shall be Top — FAU —W.H. — deemed revoked. CITYb WT�NUnd y. Tel. No.1j,F?4?� Z Hood — Fan —Other— LICENSED CONTRACTORS DECLARATION LICENSE OR I hereby affirm that I am licensed under provisions of Chapter 9 Disp' — Room Air Cond. REG.NUMBER — Class. (comryiencing with Section 7000)of Division 3 of the Business I Power Apparatus&Large Appliances DISTRICT NO. PR SED BY O}.. and Professions Code,and my license is in full force and effect. (y (f�� Size&Type HP, KW, KVA, or KVAR .Q �2L,CL G[ - O z License Number / Z2 Lic. Classic, r `� Up to 1 Incl. jFINAL V I ,) /J Over 1 to 10 Incl. DATE z VALIDATION Contractor"`^ ��V'�"' ►—� Date I O ❑ Over 10 to 50 Incl. FINAL U I am exempt under Sec. Over 50 to 100 Inc; ABY LU0 Over 100 tl B.&P.C. for this reason Services, Swbd., MCC&Ponelboords U) Dat 0-200 Amp. Under 600 V Z Signature 201 - 1000 Amp. Under 600 V ❑ Exemption for Reg. Maint. Elect. ' Over 1000 Amp. or Over 600 V SINGLE FAMILY Tem Power Pole&Appurtenances HOME OWNER-BUILDER DECLARATION p' wPP ` =a Sign with One Branch Circuit I hereby affirm that I am exempt from the Contractor's License al ' Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits Professions Code): i rO Complete Fee Schedule Com lSee _ ❑ as owner of the property, will do the work anMisc. Conduits&Conductors al the t`"t I A '�-�� s structure is not intended or offered for sale(Section 7044, Other( P )— -„ Business and Professions Code). �= cc ,_ 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 PERMIT FEE (Sub-Total) (Sec. 3097, Civ. C.). r- PLAN CHECKING FEE Lender's Name i31'i�r PERMIT ISSUING FEET` 14. Lender's Address G 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 f 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 EXPLANAT RY LANGUAGE Signature of Permittee DateF'a� r'�✓�C L ®s -� i� � - cam . fa -5 -. �.- WORKERS'COMPENSATION DECLARATION 2000tvDPW aie7 APPLI/' TI®� ®p �C�TR CALRMIT O I hereby affirm that I have a certificate of consent to self °63 �e 1� t 06G insure, or a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES i DEPT. OF PUBLIC WORKS or a certified copy thereof(Sec. 3800, Lab. C.) Policy No. Company I FOR APPLICANT TO FILL IN UOB / ❑Certified copy is hereby furnished. New Residential Bldgs. &Pools EACH NO. FEE (ADDRESS ❑Certified co is filed with the count building $ $ LOCALITY copy ' y g inspec- 1 &2-Family, Sq. Ft. tion department. I Multi-family Sq. Ft. -- NEAREST Residential Swimming Pools CROSS ST. OWNER OR Date Applicant FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' I Outlets: Rec Light Sw. 3 MAIL COMPENSATION INSURANCE First 20 �/ �� (ADDRESS (This section need not be completed if the work involved by I CITY Tel. No. the permit is for one hundred dollars($100)or less.) Total No. Additional PLAN CHECK I certify that in the performance of the work for which this APPLICANT permit Is issu d, I shall not employ any person in any manner l so as to be me s ject to the Worker Ggippe tion•Laws. Lighting Fixtures First 20 ADDRESS A� ' Additional i [� I' Total No. CITY Tel. No. Date Applicant Fixed Appliances Not Over 1 HP PERMIT pp NOTI TO PPLICANT: If, after ma this Cer icafe of PERMIT ti Exe ptio you should become s lect to th Workers' Range— Heater—D.W. o pensation provisions of the Labor Code, you must forth- Oven — Dryer —W.M.— ADDRESS qk V�`��tRsT with comply with such provisions or this permit shall be I; Top FAU —W.H. — dee_r' ed revoked. Hood — Fan —Other— CITY Tel. �I LICENSED CONTRACTORS DECLARATION LICENSE OR Dis — Room.Air Cond. — Class. C/® I hereby affirm that I am licensed under provisions of Chapter 9 � p' REG. NUMBER �s (commencing with Section 7000)of Division 3 of the Business Power Apparatus&Large Appliances DISTRICT NO. PROC SED BY >_ and Professions Code,and my license is in full force and effect. o d �i I Size&Type HP, KW, KVA, or KVAR I �.J�Q O License Num—beJr?4 Lic. Class C+ r® I Up to 1 Incl. FINAL V Contractor��,G EGc4CP� Date ® d� Over 1 to 10 Incl. DATE VALIDATION 0 ❑ Over 10 to 50 Incl. F_ FINAL U I am exempt under Sec. I. Over 50 to 100 Inc. gY W B.&P.C. for this reason Over 100 j 1 Services, Swbd., MCC&Panelboards CDZ Date: 0-200 Amp. Under 600 V — Signature G "� I 201 - 1000 Amp. Under 600 V ❑ j Exemption for Re Maint. Elect. Over 1000 Amp. or Over 600 V ry SINGLE FAMILY HOME OWNER-BUILDER DECLARATIONTemp. Power Pole&Appurtenances I hereby affirm that I am exempt from the Contractor's License I Sign with One Branch Circuit Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits ;; c• +:sar t Professions Code): - ❑ 1, as owner of the property, will do the work and the Misc. Conduits&Conductors 1 J €=11= structure is not intended or offered for sale(Section 7044, Other(See Complete Fee Schedule)_ T I;'�'AL 36 -65 Business and Professions Code). -, CONSTRUCTION LENDING AGENCY � "'-'°'-'-' I hereby affirm that there is a construction lending agency for :E EM ,I Ju.; the performance of the work for which this permit is issued ' PERMIT FEE (Sub-Total) (Sec. 3097, Civ. C.). PLAN CHECKING FEE it IL: /Q Lender's Name �j PERMIT ISSUING FEE CMV Lender's Address I Z rl ill'3'j I TOTAL FEE / I certify that I have read this application and state that the T ..� �•lv• above information is correct. I agree to comply with all County ordinances and State laws regulating Electrical wiring, and herebyauthorize representatives of this County to enter upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date r as j ,