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Home My Public Portal About5755 ROSEMEAD BLVD_Electrical__ WORKERS'COMPENSATION DECLARATION CE-806 10i81 AP rP �C -90 j ?OR EL ll E'6�RICAL PERMIT I hereby affirm that I have a certificate. of consent to self insure, CE-806G l�LL, llyG�,1 l!- 15 L�.I� or a certificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY copy thereof(Sec.3600,Lab.C.) Policy No. Company s� T� �c�/Y l/ I FOR APPLICANT TO FILL IN JOB ❑, Certified copy is hereby furnished. New Residential Bldgs.&Pools .EACH NO. FEE ADDRESS ❑ 1 &2-Family,Sq.Ft. $ — $ LOCALITY Certified copy .is filed with the county building inspection — department. Multi-family Sq.Ft. NEAREST CROSS ST Date l2 c? &&— Applicant �C�� .Le__ Residential Swimming Pools FIOWNER OR CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec Light Sw. MAIL' `3 COMPENSATION INSURANCE ,14 0 ADDRESS This section need not be completed if the work Involved b the First 20 ' ( p y Total No. CITY. , Tel.N29/; permit is for one hundred dollars($100)or less.) Additional � �' I certify that In the performance of the work for which this permit PLAN CHECK 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 I 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. I Top — FAU — W.H. — CITYTel.No. /1 LICENSED CONTRACTORS DECLARATION Hood — Fan — Other— 3 �" I hereby affirm that.I am licensed .under provisions of,Chapter 9 Disp. _ Room Air Cond. LICENSE OR Class. (commencing with Section 7000)of Division 3 of the Business and REG:NUMBER Professions Code,and my license is in full force and effect. i Power Apparatus&Large Appliances DISTRICT NO. �� SSED BY Size&Type HP,KW,KVA,or,KVAR Q, License Number � -� Lic.Class �"� Up to 1 Incl. FINAL V ./ I DATE .► (� Contractor,q/6f rn�p Ate •�- Over'1 to 10 Incl. VALIDATION Over 10 to 50 Incl. O FINAL C� ❑ I am exempt under Sec. i Over 50 to 100 Inc. BY B.&P.C.-for this reason Over 100 ` N' Services;Swbd.,MCC&Panelboards Z Date: I' 0-200 Amp.Under 600 V ' PEA Signature 201 - 1000 Amp.Under 600 V I• Over 1000 Amp.or Over 600 V " '-• ❑J Exemptidn for Reg.Maint.Elect. o SINGLE FAMILY Temp.Power Pole&Appurtenances HOME OWNER-BUILDER DECLARATION I. Sign with One Branch Circuit tai' '=v■%} I hereby affirm that I am exempt from the Contractor's License Law Additional Sign Branch Circuits for the following reason(Section 7031.5,Business and Professions Code): r 91 13Misc.Conduits&Conductors I,as owner of the property,.will do the work and the structure I& not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) — I, " and Professions Code). NC CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the I performance of the work.for which this permit is issued(Sec.3097, I PERMIT FEE (Sub-Total) ' Civ.C.). apt(�j-• .t}�� r+:w :1-: L j: r•_�:`i PLAN CHECKING FEE igf =, Lender's Name i PERMIT ISSUING FEE Lender's Address I g/ I 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 ' property for inspebtion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signa u e of mittee Date WORKERS'COMPENSATION DECLARATION ;76-663 10/e7 • APPLICATION FOR ELECTRICAL PERMIT hereby affirm that I have a certificate of consent to self Insure, CE-6o6G or a certificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY - copy therecf..(See.3800,Lab.'C.) Policy No.// � Company FOR APPLICANT TO FILL IN JOB ❑ Certified copy Is-hereby furnished, v�/'-/a" + EACH NO. FEE ADDRESS New Residential Bldgs.&Pools 1 &2-Family,Sq.Ft. LOCALITY ❑. Certified copy is filed with the county building inspection $ — $ NEAREST department. Multi-family Sq.Ft., I CROSS A-PResidRntial Swimming Pools OWNER R Date .�g „�9= plican a , FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' MAIL f COMPENSATION INSURANCE I Outlets:Rec—Light—Sw.— ADDRESS f' (This section need not be completed If-the work involved bY'the First 20 CITY Tel.No. permit is for one hundred dollars($100)or less.) Total No. Additional I certify that in the performance of the work for which this permit PLAN CHECK is issued,.I shall not•employ any person in any manner so as to ; APPLICANT become subject to the Workers'Compensation Laws. , Lighting Fixtures First 20 ADDRESS • 4 Additional Date . g Applicant ? C�tal No. CITY Tel.No. NOTICE- TO APPLICANT:. If, after making this Certificate of Fixed Appliances Not Over 1 HP ERMIT Exemption,you should become subject to the Workers'Compensation I Range_,Heater D.W. APPLICANT provisions of the Labor,Code,you must forthwith comply with such .f Oven _ Dryer_ W.M._ ADDRESS ,Y Nd-[.J G;P.94w D rl Pi provisions or this permit.shall.be deemed revoked. Top — FAU _. W.H:_ CITY Cr.Q G'Y� Tel.N LICENSED CONTRACTORS DECLARATION Hood — Fan Other I hereby affirm that I am licensed under.provisions of Chapter 9 Disp. —, Room Air Cond. LICENSE OR (commencing with Section 700.0)'of Division'3 of the Business and 'i REG.NUMBER '6G Class• Professions Code,and my license is in full force and effect. .I Power Apparatus&Large Appliances DISTRICT NO. P QCE$SED BY I �y 0 70 r— i,�-, .i Size&Type HP,.KW,KVA,or KVKIR �Q O License Number Lic.Class � Up to 1 Incl. FINAL Over 1 to 10 Incl. DATE t I VALIDATION Contractgr J/. 4"-Y s &�Date_ U • Over 10 to 50 Incl. FINAL ❑: I.am exempt.under Sec. 7 —,Over 50 to 100 Inc. BY W B.&P.C.for this reason Over 100 IL CO) Services,Swbd.,MCC&Panelboards ► Z Date- 0-200 Amp.Under 60.0 V , Signature •201 - 1000 Amp.Under 600 V F1Over 1000 Amp.or Over 600 V '. Exemption,for Reg.Maint.Elect, I , SINGLE FAMILY Temp.Power Pole&Appurtenances .` HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuitz I hereby affirm that I am exempt from the Contractor's License Law • t is l• a s or Additional Sign Branch Circuits fdt)following reason(Section 7031:5,Business and Professions 317 ,,?• f r , Misc.Conduits&Conductors 3 =t" ' ❑ I;as owner of the property,.will do the work and the structure Other(See Complete Fee Schedule)._ is not intended or offered for sale (Section 7044, Business.l. , r^jr ` and Professions Code). _ _• CONSTRUCTION LENDING AGENCY r• CHECK 59.15 I hereby affirm. that there is a construction.lendird agency for the, performance of the work for which this permit•is issued(Sec.3097,1 PERMIT FEE (Sub Total 'CHANCE ars• Civ.C.). I PLAN CHECKING FEE 1%r'J r 'Lender's.Name PERMIT ISSUING FEE �� t/-��1,� • 1 ,��(�y,6at>,:�. Lender's Address I certify that I'.have read this•application and state that the.aboveI TOTAL FEE information is correct.I agree to comply with all County ordinances, and-State laws regulating Electrical wiring, and hereby authorlie reprgsentatives of this County to enter upon:the above-mentioned property for inspection purpose's.. a SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date ' � I j WORKERS'COMPENSATION DECLARATION 76-806 10/81 • AnPp OCl�gr'�ON FOR ELECTRICAL PERMIT j J hereby affirm that I have a certificate of consent to self insure, : CE-806G Is� L� 6W l4 Y\9 f1' tl`9 f or a certificate of Workers'Compensation insurance, or a certified ; COUNTY OF LOS ANGELES BUILDING AND SAFETY J copy thereof,(Sec.3800,Lab.C.) �2 Policy No./ e!� Company "�uM`D I FOR APPLICANT TO FILL IN JOB Certified copy is herebyfurnished. ��/�' EACH NO. FEE ADDRESS New Residential Bldgs:&Pools LOCALIT145V_9 ZY ❑ 1 &2-Family,Sq.Ft. $ _ $ Certified copy is filed with the county building inspection NEAREST department. y�, JMulti-family Sq:Ft. CROSS-ST. Date 4e�,[29�plicant=�Y r' � ntial Swimming Pools OWNER OR FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec-Light-Sw.= MAIL COMPENSATION INSURANCE I ADDRESS (This section need not be completed-if the work Involved by the First 20 ' permit is for one hundred dollars($100)or lose.) Total No. Additional CITY 7e1.No. I certify that in the performance of the work.for which this permit PPLANICCHHnE�CK is issued, I shall not employ any person in any manner so as to I ' become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS Additional Lie b g Applicant �� tal No. CITY Tel.No. Date I Fixed Appliances Not Over 1 HP NOTICE TO APPLICANT:. If, after making this Certificate of Exemption,you should become subject to the Workers'Compensation Range_ Heater D.W. APPLICANT s�M� provisions of the Labor.Code,you must forthwith comply with such Oven Dryer_ W.M._ ADDRESS er N6-[4_) 4'4~R.0Ili6- provisions or this permit.shall be deemed revoked. Top FAU _ W.H. CITY G.Q 'I•el.Nd LICENSED CONTRACTORS DECLARATION. Hood _ Fan Other_ C� I hereby affirm that'I am licensed under provisions of Chapter 9LICENSE OR Disp. Room Air Cond. REG.NUMBER , Lrb'GG class. a"(� (commencing with Section 7000Y of Division'3 of the.Business and Professions Code,and my license is in full force and effect. DISTRICT NO. P CESSED BY Power Apparatus&Large Appliances &J`06pce- ,�` f Size&Type HP,KW,KVA,or KVAFi d• d 0 License Number Lic.Class • I Up to 1 Incl. FINAL U Over 1 to 10 Incl. DATE 1 ' VALIDATION Contract9& e S SI& Date 1-2153e --3SAY Over 10 to 50 Incl.' FINAL L U ❑ I am exempt under Sec. 1 Over 50 to.100 Inc. BY W Over 100 B.&P.C.for this reason U) Services,Swbd.,MCC&Panel.boards Z Date: 0-200 Amp.Under 600 V Signature. 201 - 1000 Amp.Under 600 V F1 Exemption 1000 Amp.or Over 600 V Exemption for Reg.Maint.Elect. SINGLE FAMILY Temp.Power Pole&Appurtenances HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit 49 1 A I hereby affirm that I am exempt from the Contractor's License Law ,additional Sign Branch Circuits � J for the following reason(Section 7031.5,Business and Professions' Code): Misc.Conduits&Conductors ❑ t as owner of the property,will do the work and the structure is not intended or offered for sale (Section 7044, Business I Other(See Complete Fee Schedule) -55 tai and Professions Code). CK ^€_ CONSTRUCTION LENDING AGENCY -'HL~'` 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 I_i,,_.j ,,,_i! L2- 17 PERMIT ISSUING FEE os-7 ti fir 1 r3: Lender's Address L°��. - 3;i s_'e+e I 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 authonzel representatives of this County to enter upon the above-mentioned property for inspection purpose's. C SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date