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Home My Public Portal About6202 ROSEMEAD BLVD_Electrical__ l+?.YvyORKERS'COMPENSATION DECLARATION 76-683' 10/81 APPLICATION FOR ELECTRICAL PERMIT - CE-8080 (firm that I have.a-certificate of consent to self insure, �or� :: a of Workers',Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY copy (bac.3800,Iib.C.)., Policy No. Company r-0040 FOR APPLICANT TO FILL IN JOB rtified copy Is'hereby furnished. EACH NO. FEE ADDRESS New Residential Bldgs.&Pools Certified c py isAfiled with the .county building inspection 1&2-Famlly,Sq.-Ft. $ — $ LOCALITY � depart nt. _—� Multi-family Sq.Ft. — NEAREST Residential Swimming Pools CROSS ST Date Applicant A� '—_Tt � OWNER OR C RTIFICATE OF EXEMPTION FROM WORKERS` MAIL FIRM NAME �� ( >f / COMPENSATION INSURANCE Outlets:Rec Light °� t 2 •� ADDRESS �a (This section need not be completed If the work involved by the First 20 permit is for one hundred dollars($1 � - Additional or less.) Total No. CIT LA;,, Tel.No. 6 (� li certify that in the performance of the work for which this permit n Pu CCANT K 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 NOTICE TO APPLICANT, If, after making.this Certificate of PERMIT 1 Exemption,you should become subject to the Workers'Compensation Range_ Heater_ D.W. _ APPLICANT provisions of the Labor Code,you must forthwith comply with such Oven _. Dryer— W.M._ ADDRESSA& 314 ( � provisions or,this permit shall be deemed revoked. Top FAU W.H. CITYTel.No. LICENSED CONTRACTORS DECLARATION Hood — Fan Other_ I hereby affirm that,I am licensed under provisions of Chapter 9 Disp. Room Air Cond. LICENSE OR Class. Qp (commehcing with Section 7000),of Division 3 of,the Business and REG.NUMBER a ��cr 1�7 Professions Code,and my license is in full force and effect. Power Apparatus&Large Appliances DISTRICT NO. P. S D y Size&Type HP,KW,KVA,or KVAR O� License Number '@LqID!C6 Lic.Class 10p Up to 1 Incl. FINAL Contractor /Y.yat-IYa.(/ f-vuate Over 1 to 10 Incl. DATE VALIDATION; Q Over 10 to 50 Incl. FU- ?7A F ❑ I.am exempt under Sec.. Over 50 to 100 Inc. B a Over 100 , BAP:C.for this reason. z Services,Swbd.,.MCC&Panelboards , 0-200 Amp.Under 600 V Slgnafu '-�- 201 - 1000 Amp.Under 600 V ❑ Over 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 I hereby affirm that I am exempt from the Contractor's License Law a for the foilowing'reason(Section 7031.5,Business and Professions Additional Sign Branch Circuits Code). -7 – ❑ Misc.Conduits&Conductors " I,as owner of the property,will do the work and the structure : is not.intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) _ . and Professions Code). , : :.a# '""'ate-"_o ' N 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(Sec.3097, PERMIT FEE (Sub-Total) Civ.C.). PLAN CHECKING FEE Lender's Name D j-, -N'_j";ICU • PERMIT ISSUING FEE - , 41 Ci 7 Lender',s.Address. �:^ I certify that I have read this;application and state that the above TOTAL FEE ; information is correct;I agree to comply with all G`ounty 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 EXPLANATORY LANGUAGE 5ignat'ure of Permittee Date 1, b 'firm that I COMPENSATION DECLARATION 76-663 10/81 APPLICATION FOR ELECTRICAL PERMIT f'eby affirm that I have a certificate of consent to self insure, CE-8066 mor a certificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY copy thereof(Sec.380WAh.C.) NAlcy No. Company FOR APPLICANT TO FILL IN JOB ❑ Certified copy is herebyfurnished. EACH NO. FEE ADDRESS New Residential Bldgs.&Pools ❑ I 1 &2-Family,Sq.Ft. $ — $ LOCALITY Certified copy is filed with the county building inspection _ NEAREST department. Multi-family Sq.Ft. CROSS ST. A Date Applicant Residential Swimming PoolsOWNER OR j FIRM NAME L CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec—Light—Sw.— MAIL ! COMPENSATION INSURANCE ADDRESS (This section need not be completed if the work involved by the First 20 Total No. Additional CITY permit is for one hundred dollars($100)or less.) 2 Tel.No. I certify that in the performance of the work for which this permit PLAN CHECK 13 is issued, I shall not employ any person in any manner so as to APPLICANT become subject to the orkers'Compensation Laws. Lighting Fixtures First 20 ADDRESS Additional Total No. CITY Tel.No. Date pplicant, -, Fixed Appliances Not Over 1 HP PERMIT — NOTICE TO APPLICANT: If, after mal�6• g 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 g provisions or this permit shall be deemed revoked. Top — FAU _ W.H. LICENSED CONTRACTORS DECLARATION Hood — Fan _ Other_ CITY Tel.No. 1 hereby affirm that I am licensed under provisions of Chapter 9LICENSE OR Disp. — Room Air Cond. REG.NUMBER Class. I (commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license is in full force and effect. DISTRICT NO, ! PROCESSED B Power Apparatus&Large Appliances i Size&Type HP,KW,KVA,or KVAR U I License Number Lic.Class Up to 1 Incl. FINAL 130Over 1 to 10 Incl. DATE VALIDATION, O Contractor Date Over 10 to 50 Incl. tV— ❑ FI Y I am exempt under Sec. Over 50 to 100 Inc. d BAP..C.for this reason Over 100 Date: N Services,Swbd.,MCC&Panelboards O Z 0-200 Amp.Under 600 V Signature 201 - 1000 Amp.Under 600 V __......_... El Exemption 1000 Amp.or Over 600 V Exemption for Reg.Maint.Elect. SINGLE FAMILY Temp.Power Pole&Appurtenances 2' HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit ,� �• I hereby affirm that I am exempt from the Contractor's License Law ACCT.0 n'�a for the following reason(Section 7031.5,Business and Professions Additional Sign Branch Circuits 3M725. 50 a .. I,as owner of the property,will do the work and the structure Misc.Conduits&Conductors 1 I 1 E vis'not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) _ ® Y�T � and Professions Code). �y CONSTRUCTION LENDING AGENCY CASH I Z®50 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 N GMS—M1 71 7/89 Lender's Name � 'l I PERMIT ISSUING FEE 4-376 1 0141125 Lender's Address I certify that I have read this application and state that the above TOTAL FEE 5 i 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 propert r inspection p pose SEE REVERSE FOR EXPLANATORY LANGUAGE Si nature of mitt ate