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HomeMy Public PortalAbout6004 ROSEMEAD BLVD_Electrical__ WORKERS'COMPENSATIONDECLARATION !CEAA-806G (2-80) APPLICATION FOR ELECTRICAL PERMIT I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY insure,or a certificate of Workers'Compensation Insurance,or a certified copY�h reof(Sec 0 a .C.) G'G 2D -' 7OFs"� /a+� FOR APPLICANT TO FILL IN Job"ryf �t Policy No. Company (1}too T— Z 0� New Residential Bldgs.&.Pools EACH NO. FEE ADDRESS Certified copy is hereby furnished. , 1 &2-Family,Sq.Ft. — $ LOCALITY —7a.11 Ile el ❑ Multi-family Sq. Ft. NEAREST' Certified copy is filed with the coun ldin i pection CROSS ST t� Ar departmen Residential Swimming Pools OWNER OR .yf ! � nn Date. 2rCATE A FIRM NAME �Lac( JIl. �0.. App ica Outlets: Rec._Light Sw. ADDRESS ZZ First 20 1;44 CERTI OF EXEMPTIO FROM WORKERS' Total No. Additional CITY [.A ° Tel No. p � } COMPENSATION INSURANCE PLAN CHECK APPLICANT (This section need not be completed if the work. involved U Fixtures First 20 by the permit is for one hundred dollars ($100) or less.) Lighting ADDRESS M Additional Total No. O I certify that in the performance of the work for which thisFixed Appliances Not Over 1 HP' CITY Tel No.. permit is issued, I shall not employ any person in any manner PERMIT­— so as to become subject"to the Workers'Compensation Laws. Range_Heater D.W._ APPLICANT AJO-ftcrr, �. d Oven _ Dryer_W.M._ ADDRESS j Z /I�a Date Applicant Top _FAU _W.H.. n Hood _ Fan _Other_ CITY Tel No. .Q g NOTICE TO APPLICANT: If, after making this Certificate.of Disp. _Room Air Condom LICENSE CYR Exemption, you should become subject to the Workers' REG.NUMBER3M.55"2-class Compensation provisions of the Labor Code, you must forth- Power Apparatus&Large Appliejlces DISTRICT NO. PROC SSED BY with comply with such provisions or this permit shall be deemed revoked. Size&Type HP,KW,KVA,or KVAR d� Up to 1,Incl., v • - FINAL. Over 1 to 10 Incl. DATE LICENSED CONTRACTORS DECLARATION Over 10 to 50 Incl. VALIDATION , I hereby affirm that Iam licensed under provisions of Chapter Over 50 to 100 Inc. FINAL 9 (commencing with Section'7000)of Division 3 of the Busi- Over 100 BY, ness and Professions.Code,and my license is in full force and effect.. (Services `� _ `� 0-200 Amp.Under 600 V /SJq��/ri vicense Number:9 s+s�.ZLic.:Class- y T I 201-1000 Amp.Under 600 V Contractor/vim �Q-K 1/ +-.K�' Over 1000 Amp.or Over 600•V HOME OWNER-BUILDER DECLAR? I`8® ,Temp.Power Pole&Appurtenancesore I hereby affirm that I am exempt from the Contractor's' Sign with One Branch Circuit License Law for the following reason (Section 7031.5, Busi= Additional Sign Branch Circuits ness and Professions Code): C 7 I IMisc.Conduits&Conductors ` �( 0 I, as owner of the property, will do the work and the (Other(See Complete Fee Schedule)— n o c c a 1 structure is not intended or offered for sale (Section. 7044,Business and Professions Code). 9 o c 1 7.0 0 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency c fo the performance of the work for which this permit is o u c 1' f (PERMIT FEE (Sub-Total) issued(Sec.3097,Civ.C.). I /� � 7 ' 1,-80 Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee) Lender's Address PERMIT ISSUING FEE I I certify'that I have read this application and state that the TOTAL FEE ! 7 above information is correct.I agree to comply with all County ordinances and State laws regulating Electrical wiring, and hereby authorize representative of this County to enter upon I Ate-ment er r inspection purposes. r SEE'REVERSE FOR EXPLANATORY LANGUAGE Signature.o Perm ee D to WORKERS'COMPENSATION DECLARATION !76A663 APPLICATION FOR ELECTRICAL PERMIT 'CCE-806E-906G (2-BOJ I hereby affirm that I have a certificate of consent to self ' COUNTY OF LOS ANGELES I BUILDING AND SAFETY insure,or a certificate of Workers.'.Compensation Insurance,or a certified copy thereof(Sec.3800,Lab.C.) " FOR APPLICANT TO FILL IN JOB �- Policy No. Company. EACH NO. FEE ADDRESS New Residential Bldgs.&Pools Certified copy is hereby furnished. 1 &2-Family,Sq.Ft. $ — $ LOCALITY ❑ Ft. NEAREST Certified copy is filed with the county building inspection Multi-family Sq. . CROSS ST department. Residential Swimming Pools_ i OWNER OR FIRM NAME Date Applicant Outlets: Rec.—Light Sw. MAIL //�� First 20 ADDRESS U) CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. Additional CITY U Tel No. COMPENSATION INSURANCE PLAN CHECK o. (This section need not be completed if the work involved I APPLIdANT iJ by the permit is for one hundred dollars ($100) or less.) Additional Lighting Fixtures. First 20 ADDRESS 1 Total 1 certify that in the performance of the work for which this Fixed Applppl iances Not Over 1 HP CITY Tel No. t . permit is issued, I shall not employ any person in any manner PERMIT so as to become subject to the Workers'Compensation Laws. Range_Heater D.W._ APPLICANT a rn at �./ Oven _ Dryer_W.M._ ADDRESS e � r Applicant 1� Top _FAU _W.`H.._ Hood _ Fari _O,ther_ CITY Tel No. . NOTICE TO APPLICANT: If, after making this Certificate of Disp. _Room Air Cond— LICENSE OR Exemption, you should become subject to the Workers' REG.NUMBER 29 711 Class Compensatibn provisions of the Labor Code, you must forth- :' Power Apparatus&Large Appliances DISTRICT NO. PROCE 6ED BY with comply with such provisions or this permit shall be Size&Type HP,KW,KVA,or KVAR deemed revoked. • Up to 1 Incl. -6 FINAL LICENSED CONTRACTORS DECLARATION Over 1 to 10 Incl.. DATE VALIDATION Over 10 to 50 Incl. JJ t I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. FINAL 9 (commencing with Section 7000)of Division 3 of the Busi- Over 100 BY ness and Professions.Code,and my license is in full force and effect. Services License Numb // iq.Class �_5S 0-200 Amp.Under 600 V ��Jff 2011000 Amp.Under 600 V C! Contract4u4d Date •— dfA' f Over 1000 Amp.or Over 600 V 7 HOMEOWNER-BUILDER DECLARATION Temp.Power Pole&Appurtenances 1 hereby affirm that I am exempt from the Contractor's Sign with One Branch Circuit. License Law for the following reason (Section 7031.5, Busi- Additional Sign Branch Circuits ness and Professions Code): Misc.•Conduits&Conductors j 3 1, 1 A I, as owner of the property, will do the work and the Other, (See Complete Fee Schedule)— structure is not intended or offered for sale (Section it o o o 'o o 2 7044,Business and Professions Code). 2 0'0 2$ 5 0 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is PERMIT FEEr issued(Sec.3097,Civ..C.)'. (Sub-Total.) �� o 0 0 2�' Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee) 0 4 2 u—v 2 Lender's Address PERMIT ISSUING FEE ,TO I certify that I have read this application and state that the TOTAL FEE � V above information is-correct.I agree to comply with all County ordinances and State haws regulat' g Electrical wiring, and hereby au rNe re an tives of his County to enter upon the ab -m t' c arty for nspection pu poses. SEE'REVERSE FOR EXPLANATORY LANGUAGE Signature.of er tt a Date WORKERS'COMPENSATION DECLARATION I7SA663 I ICE-806G (2-80) APPLICATION FOR ELECTRICAL PERMIT I.hereby affirm that I have a certificate of consent to self ( COUNTY OF LOS ANGELS ILDING AND SAFETY insure,or a certificate of Workers'Compensation Insurance,orf a certified c p6t er,of 2c.3800,Lab.C.) 6 tJFILL JOB Policy No. Company FOR APPLICANT TO EACH N NO. E ADDRESS New Residential Bldgs.&Pools to Certified copy is hereby furnished. 1 &2-Family.Sq. Ft. Agm $ — $ ' LOCALITY E) Certified copy is filed with the count building Multi-family Sq. Ft. �� © — LO CROSS ST y g inspection Residential Swimming Pools department. �/'�/-- - OWNER OR Date 7"eApplicant 1� ��� 2�C I FIRM NAMjjEf s" �j,( � /. ' �c,1 Outlets: Rec._Light First ADDRESSf°Za7 v" First 20 CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. Additional CITY A Tel No"f, COMPENSATION INSURANCE PLAN C ECK d ` APPLICANT (This section need not be completed if the work involved Lighting Fixtur First 20 U by the permit is for one hundred dollars ($100) or less.) Additional ADDRESS Total No. I certify that in the performance of the work for which this Fixed Appliances Not Over 1 HP CITY Tel No. O pbrmit is issued, I shall not employ any person in any manner PERMIT U so as to become subject to the Workers'Compensation Laws. Range_Heater D.VV APPLICANT(,' % G /J C W Oven `{wryer W.M._ ADDRESS 0L/o7� /I/ed G . /,/ is Date Applicant Top FAU"1'-W.H.._ Hoods—TtR 'Other— CITY. . Tel d.1 . NOTICE TO APPLICANT: If, after making this Certificate of Disp. �—RGom Air Condi_ LICENSE OR , . Exemption, you should become subject to the Workers' REG.NUMBE Cess `f0 Compensation provisions of the Labor.Code; you must forth- Power Apparatus& Large Appliances DISTRICT NO. PROCES BY with comply with such provisions or this permit shall be: Si &Type HP,KW,KVA,or KVAR Size d� deemed revoked.. Up to 1 Incl: IA��_/ FINAL LICENSED CONTRACTORS DECLARATION Over 1 to 10.Incl. DATE - 4.10 to 50 Incl. "�� � �. VALIDATION I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. FINAL 9 (commencing with Section 7000)of Division 3 of the Busi- OverBY100 ®--�--�..1�- • ness and Professions.Code, and my license is in full force and effect. �:O��� Services rider 600 V License Number Lic.Class 201-1000 Amp:Under 600 V Corftraatbr erica Date Over 1000 Amp.or Over 600 V HOME OWNER-BUILDER DECLARATION Temp.Power Pole&Appurtenances Sign with One Branch Circuit I hereby affirm that I am exempt from the Contractor's IAdditional.Sign Branch Circuits License Law for the following reason (Section 7031.5; Busi- ness and Professions Code): U 9 Misc.Conduits&Conductors. I, as owner of the property, will do the work and the Other(See Complete Fee Schedule)— ' structure is not intended or offered for sale (Section 7044 Business and Professions Code). CON..STRUCTION LENDING AGENCY 0 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is PERMIT FEE (Sub-Total) p e G `� 1. 1.0 c:. issued(Sec. 3097,Civ.C.). Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee) `( 2 7—8 1 Lender's Address PERMIT ISSUING FEE I certify that I have read this application and state that the TOTAL FEE (/O .above information is correct.I agree to.comply with all County ��/,/a ordinances and State laws regulating Electrical wiring, and hereby authorize representatives of this County to enter upon 7 G/ the ab mentioned pro rty for Inspection purposes. SEE'REVERSE FOR EXPLANATORY LANGUAGE Siowture of Permittee Date