The URL can be used to link to this page

Home My Public Portal About5799 ROSEMEAD BLVD_Electrical__ WORKERS'COMPENSATION DECLARATION 20-W19 DPW 3187 I hereby affirm 'fhgf I have a.certificate of.consent to self :CE-BD6G APPLICATION FOR ELECTRICAL PERMIT •.inSAI or a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELESDEPT. OF PUBLIC WORKS ora certified co thereof(Sec, 3800, Lab. C.). Poh 'No '✓ + Company _ `1 Y APPLICANt TO FILL•IN JOB' , ��jl'' FOR [� Certified copy is hereby furnished. /O•a Zi New Residential Bldgs. &Pools EACH NO. FEE 'ADDRESS J 1i,i .. LOCALITY ❑Certified copy is filed. with the..county building inspec- 1 &2-Family,Sq, Ft: - ... $ . C '' tion departm- _t. Multi-family Sq. Ft. NEAREST f pi Date ., Z Applica... Residential'Swimrrming Foals CROSS OWNER OR CERTIFICATE:.OF EXEMPTION FROM WORKERS' Outlets: RecLightSw. 1 +�� FIRM NAME COMPENSATION INSURANCE ' First 20 MAIL _ (This section need not be completed if,the-work Involved by ADDRESS Tel. No. the permit Is for one hundred dollars(5100)•or,less.) Total No. Additional 3 oz B� - I certify.that.in the performance:of the work for which ,this PLAN CHECKAPPLICANT permit is issued, I shall not.employ any person:in any manner so as to'become sublect to-The Workers'Compensation Laws. Lighting Fixtures First 20 ®• ADDRESS ' Additional CITY Tel. No. Total No. � Ad Date Applicant +{ Fixed Appliances Not.Over'1 HP PERMIT O APPLICANT: If; after making Phis Certificate of Range— Heater—•P.W. _ APPLICATION `ef YtNo1 N l�✓Git.. Exemption; NOTICE Tyou should become :subject to the Workers.' 9 �d Compensation provisions•of'the Labor Code, you-must.forth- Oven _ Dryer .—W.M.— ADDRESS /23 n!✓'_., ,014 with comply with such provisions or this_.permii :shall be Top — FAU W.H. — a) deemed revoked. CITY . 'pH Tel. No� /1 Hood — Fan —Other— LICENSED CONTRACTORS DECLARATION- LICENSE OR q !.hereby affirm that lam licensed under provisions of Chapter 9 Disp. _ Room Air Cond.. _ REG.NUMBER 3�7./ Class. (commencing with Section 7000)of Division-3.of the Business Power Apparatus&Large Appliances DISTRICT NO. P O ESSED BY and.Professions Code,and.my'license is in full force and effect. " d :Size&Type HP, KW,,KVA, or KVAR � 0 License Number `� ic. Class Up to I Incl. FINAL U Z Over 1 to 1.0 Incl. DATE VALIDATION. Er Contractor %!��( ate ` v 0 Over 10 to 50 Incl. i— FINAL 0 I am exempt under Sec. Over 50 to 100 Inc. BY 117 B..BP.C.for•this reason Over 100 0- .Services, Swbd., MCC&Ponelboards Z Date: 0-.200 Amp: Under 600 V — Signature 201 :,1'000 Amp.,Under 600 V Over 1000 Amp. or Over.600 V J. ❑ Exemption for Reg. Maint. Elect. ; SINGLE.FAMILY } HOME OWNER-BUILDER DECLARATION Temp.'Power Pole&Appurtenances; +ry � I hereby affirm that'I am exempt from the Contractor's{icetise .Sign with'One Branch Circuit tfi.;.•I �a Law for the following reason(Section 7031.5, Business and Additional Sign Branch Circuits -313-:'1'7 Professions Code): r ❑ I, as.owner of the property, will.do the work and the Misc. Conduits.&Conductors .structure it not intended or offered for sale(Section 7044; ,Other(See Complete Fee Schedule)_ . , ; ' ,.sc. Business'anti Professions Code). ® S S CONSTRUCTION LENDING AGENCY S'1 I hereby affirm that there is a construction.lending agency for ITS'13 the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) ,.f+s� (Sec. 3007, Civ. C.). j' ,L r 1•f{ 195 2-2 PLAN CHECKING FEE (% -err r Lenders Name PERMIT ISSUING FEE +�'}},ti•� +J' Lender's Address I certify that I have read this application and state that the TOTAL FEE / above information is correct. I agree to comply with all CountyA.IL,i, �1��:.,; ordinances:and State laws regulating Electrical wiring, and hereby authorize representatives of:this County to enter upon 4157, ,_, the above=mention property for•inspection purposes. ��••16 AN ';5 (� SEE'REVERSE FOR EXPLANATORY LANGUAGE - " ��Gr� Signature of Permittee Date ®s it D WORKERS'COMPENSATION DECLARATION j 1W-0019 DPW 3/87 O 1 hereby affirm that I-have.a certificate-of.consent to self j: � APPLICATION FOR E :ECTRICAL PERMIT 'insure;or a certificate of Workers'Compensation Insurance; COUNTY OF LOS ANGELES j DEPT. OF PUBLIC WORKS or a certified coRy thereof.(Sec. 3800, Lab. C.) f Policy No: L Company 4 T� ,T/d/1l0 FOR APPLICANT TO FILL IN JOB ADDRESS ❑Certi ied copy is hereby furnished. I New Residential Bldgs. &Pools P NO. FEE _ LOCALITY 10 Certified co is filed with the county building inspec- $ - py,,,' pec- 1 &2=Family, Sq. Ft. - tion department. Multi-family Scli ft. — NEAREST CROSS ST. Date —4-RApplicant -9.4,Js Residential Swimming Pools OWNER OR �_ FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' I Outlets: Rec Light Sw._ MAIL COMPENSATION INSURANCE ADDRESS First 20 IT 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 - /6 IPLAN CHECK I certify that in the performance of the work for which this APPLICANT permit is issued, I shall not employ any person in any manner Lighting Fixtures First 20 ADDRESS so as to become subject to the Workers'Compensation Laws. Additional Date Applicant. Total No. I CITY Tel. No. Fixed Appliances Not Over 1 HP PERMIT NOTICE TO APPLICANT; Ifs .after making this Certificate of 1 APPLICATION /d�/.(,S' Exemption; you should become subject to. the Workers' Range— Heater—D.W. — Compensation provisions of the Labor Code, you must forth- Oven — Dryer —W.M._ ADDRESS with comply with such provisions or this permit shall be i Top . — FAU CITY W.H.•— deemed revoked. Hood — Fan —Other Tel. No.�� — � LICENSED CONTRACTORS DECLARATION �' LICENSE OR li Disp, _ Room Air Cond. N . REG. UMBER Class.e4er I.hereby affirm that I am Iicensed.under provisions of Chapter 9 (commencing with Section 7000).of Division 3 of the Business Power Apparatus&Large Appliances -DISTRICT NO. P SED BY d and Professions Code,and my license is in"full force and effect. li r Size&Type HP, KW, KVA, or KVAR �' 0 License Number Lic. ClassUp to 1 Incl. FINAL ' DATE Over 1 to 10 Incl. _ !92- VALIDATION 0 Contractor s Date .. — 'a \ Over 10 to 50•Incl: FINAL U ❑ I am exempt under Sec. 'Over 50 to 100 Inc. BY B.&P.C.for this reason Over 100 I d Servides., Swbd..,MCC&Panelboards Z Date; 0-200 Amp. Under 600 V Signature 201 - 1000 Amp. Under 600 V Over 1000 Amp, or Over 600 V El Exemption for Reg. Maint. Elect. _ SINGLE FAMILY Tem Power Pole 8 Appurtenances HOME OWNER-BUILDER DECLARATION P• 1 y Sign with One Branch Circuit s:, I hereby affirm that I am exempt from the Contractor's License .�;1.•: Law for the following reason (Section 70.3.1.5, Business and 'Additional Sign Branch Circuits Professions Code): i 1�1=;'1i' Misc. Conduits 8 Conductors =• rn+ �t —5--1,❑ I, as owner of the property, will do the work and the j t 1 '� structure is not intended or offered for sale(Section 7044, Other(See Complete Fee Schedule)_ Business and Professions Code). CONSTRUCTION LENDING AGENCY I' i iisYL .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 y �. ;; PERMIT ISSUING FEE O� s -' '- yr( Lender's Address TOTAL FEE I certify that I have ead this application and state that the .S abA ion is rrect..1 agree to comply with all County ordStat laws regulating Electrical wiring, and heze tatives of this County to enter upon thei I rty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ®s Signature 61 Fermittee Date tl '