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Home My Public Portal About6248 ROSEMEAD BLVD_Electrical__ WORKERS'COMPENSATION DECLARATION 78 883 10/81 I hereby affirm that 1 have a certificate of consent to self insure, CE oeG APPLICATION FOR ELECTRICAL PERMIT or a certificate of Workers' Compensation insurance, or a certified COUNTY OF LOS ANGELES i BUILDING AND SAFETY copy thereof,(Sec..3800,Lab.C.) Policy No: Company FOR APPLICANT TO FILL IN JOB J ❑ Certified copy is hereby furnished. flew Residential Bldgs.&Pools EACH NO. FEE ADDRESS ❑ Certified copy is filed with the county building inspection 1 &2-Family,Sq.Ft. $ — $ LOCALITY ,� Z9 if'r 71"Ilq Sq.Ft. NEAREST department. Multi-familyCROSS ST. �O 411fZ ✓e Residential Swimming Pools OWNER OR Date Applicant FIRM NAME Mer)C& n ' CERTIFICATE OF EXEMPTION FROM WORKERS' MAIL COMPENSATION INSURANCE Outlets:Rec—Light_Sw.— rte/ � First 20 �i ADDRESS /11.41 .f fQ (This section need not be completed If the work Involved by the Total No. Additional I CITY l� Tel.No.� permit Is for one hundred dollars.($100)or less.) �C 1 certify that in the performance of the workfor 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 Total No. Additional CITY Tel.No. Date S �9 ftPlicant NOTICE TO APPLICANT: If, after making this Certificate of Fixed Appliances Not Over 1 HP _ ' PERMIT 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._ I ADDRESS. %3„f provisions or this permit shall be deemed revoked. Top FAU W.H. LICENSED CONTRACTORS DECLARATION Hood _ Fan Other_ ` CITY Tel.No.3"` a 2AV I hereby affirm that•I am licensed under provisions of Chapter 9 LICENSE OR (commencing with Section 7000)of Division 3 of the Business and Disp. — Room Air Cond. REG.NUMBER Class. /� Professions Code,and my license is in full force and effect.' Power Apparatus&Large Appliances DISTRICT NO P SSED Size&Type HP,KW,KVA,or KVAR l K,License Number Lic..Class Y Up to 1 Incl. i FIN ` 8 Over 1 to 10 Incl. D E V LIDATION Contractor Date Over 10 to 50 Incl. I INAL El ti I am exempt under Sec. Over 50 to'100 Inc. LILI B.&P.C.for this reason Over 100 A N ervices,Swbd.,MCC&Panelboards ' Z Date: 0-200 Amp.Under 600 V Signature 201 - 1000 Amp.Under 600 V ❑ Elect. Exemption for Reg.MainOver 1000 Amp.or Over 600 V I� t. i� SINGLE FAMILY emp.Power Pole&Appurtenances HOME OWNER-BUILDER DECLARATION ign with One Branch Circuit � I hereby affirm that I amexempt from the Contractor's License Law ditional Sign Branch Circuits ACCT.g for the following reason(Section 7031.5,Business and Professions Code): 3307 18.00 iso.Conduits&Conductors El 1.as owner of the property,'will do the work and the structure they(See Complete Fee Schedule) _ 1 ITEMS Is not intended or offered for sale (Section 7044, Business and Professions Code). li poll. TOTAL IS®00 CONSTRUCTION LENDING AGENCY I CHECK +. () I hereby affirm that there Is a construction lending agency for the performance of the work for which this permit is issued(Sec.3097, DERMOT FEE (Sub Total) CHANGE ;00 C.iv.C.). LAN CHECKING FEE I L'ender's Name 0000-0001 5/22/90) ERMIT ISSUING FEE that 0842 1 AM 10 10 have read this application and state that the above TAL FEE I certify thha ° Information is correct.I agree to comply with all County ordinances 1 and State laws regulating Electrical wiring, and hereby authorize r6presentatives of t ' County to enter upon the above-mentioned Y p i purpo's SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permitte Date WORKERS COMPENSATION DECLARATION 76-663 10/81 APPLICATION FOR ELECTRICAL PERMIT {� LI l•iiefeby affirm that I have a certificate of consent to self insure, CE-806G or a certificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY copy thereof(Sec.3800,Lab.C.) Policy No. Company FOR APPLICANT TO FILL IN JOB ElCertified Certified copy is hereby furnished. New Residential Bldgs.& Pools EACH NO. FEE ❑ 1 & 2-Family, S Ft. $ — $ LOCALITY Certified copy is filed with the county building inspection y� q department. Multi-family Sq.Ft. — EFIRM T r ST. Date Applicant Residential Swimming Pools OR ME CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec Light — Sw. — MAIL �./ COMPENSATION INSURANCE ADDRESS -C7 (This section need not be completed if the work involved by the First 20 Total No. Additional CITY Tel.No. permit is for one hundred dollars($100)or less.) I certify that in the performance of the work for which this permit APPLICANT T /j is issued, I shall not employ any person in any manner so as to become subject to the Workers'Compen ion Law Lighting Fixtures First 20 ADDRESS _ Additional ��c, Total No. ( CITY Tel.No. /,? Date /S —� /Applican 7 t,� Y l NOTICE TO APPLICANT: If, after making this Certificate of Fixed Appliances Not Over 1 HP PERMIT Exemption,you should become subject to the Workers'Compensation Range_ Heater_ D.W. _ APPLICANT is A provisions of the Labor Code, you must forthwith comply with such Oven _ Dryer _ W.M._ ADDRESS provisions or this permit shall be deemed revoked. Top — FAU _ W.H. _ ) � � 5! fLJ LICENSED CONTRACTORS DECLARATION Hood — Fan CITY Tel.No.V4(Other_ - I hereby affirm that I am licensed under provisions of Chapter 9 LICENSE OR Disp. — Room Air Cond. (commencing with Section 7000) of Division 3 of the Business and REG.NUMBER ` �i 3 Class. Professions Code,and my license is in full force and effect. Power Apparatus& Large Appliances DISTRICT NO. P CESS D BY >" 0-10 Size & Type HP,KW,KVA,or KVAR �d �`tLr-��J`C� Q License Number ��l 3 Lic.Class Up to 1 Incl. FINAL f U Over 1 to 10 Incl. DATE Contractor T�Z�'f^�"' "" Date VALIDATION 0 Over 10 to 50 Incl. FIN V ❑ I am exempt under Sec. Over 50 to 100 Inc. , 01 LLJ a' B.&P.C.for this reason Over 100 (n Services, Swbd.,MCC &Panelboards ► Z Date: 0- 200 Amp.Under 600 V Signature 201 - 1000 Amp.Under 600 V ❑ Exemption for Reg.Maint.Elect. Over 1000 Amp. or Over 600 V 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 Additional Sign Branch Circuits for the following reason (Section 703 1.5,Business and Professions Code): ❑ 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) pop. Professions Code). '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 PERMIT ISSUING FEE Lender's Address / I certify that I have read this application and state that the above TOTAL FEE C information is correct. I agree to comply with all County ordinances and State laws regulating Electrical wiring, and hereby authorize representatives of this fa6u ty to er upon the above-mentioned p[opert9'fv i pecti os SEE REVERSE FOR EXPLANATORY LANGUAGE -n ure of rermittee Date i ' WORKERS'COMPENSATION DECLARATION 09-8066 1p81 APPLICATION FOR ELCTRICAL PERMIT' I'hereby affirm-that I have a certificate'of consent to self insure, or a•certificate of Workers' Compensation Insurance, or a certified ' COUNTY OF LOS.ANGELES BUILDING AND SAFETY copy thereof(Sec,38OO;Lab.C.) Policy No. - Company FOR APPLICANT TO FILL IN JOB ❑ Certified:co is hereby furnished. EACH NO. FEE ADDRESS it a - e�ecgyl PY New Residential Bldgs.&Pools 1 &2-Family,S.q..Ft. $ — $ LOCALITY ` ❑ Certified copy is filed with the .cbutity building inspection. — � NEAREST - - department. Multifamily Sq.Ft. NEARS Residential Swimming Pools. 3T. I. OWNER OR ° Date _ Applicant .. _._ ( FIRM44AME CERTIFICATE OF EXEMPTION•FR.OK4 WORKERS' MAIL Outlets:Roo—Light—Sw. • COMPENSATION INSURANCE � ADDRESS (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) , certify that in the•performance of the work.for which this permit PLAN'CHECK I 1 � P APRLICAN'r islasued; I shall not employ any person in any manner so as, to .I become.subject to the Workers'Compensation Laws. 1 ` Lighting Fixtures First 20 ADDRESS Additional amu. Total No. CITY Tel.No. � Date.�„ ;! Applicant��✓✓✓✓, �{ Fixed Appliances Not Over 1 HP) PERMIT •NOTICE TO .APPLICANT.: If., after making• this Certificate of i 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 I Oven Dryer_ W.M._. F ADDRESS provisions or this permit shall be deemed revoked. I Top FAU W.H. _ LICENSED CONTRACTORS DECLARATION Hood'_ Fan Other_ CITY I,herebyaffirm that 1•am licensed under �r provisions of Chapter 9 Disp. Room Air Cond. — o Class.��O Tel.N LICEN OR (commencing with Section 7000)'of Division 3 of the Business and f REG.NUMBER OJ Professions Code,and my license.is in full force and effect: DISTRICT NO. PROCESSE Power Apparatus&Large Appliances /f d Size&•Type.HP,KW,KVA,or KVAR ��l/f 0 License Number Ila - Lic.:.Class e-7 ` FINAL _ V Up to�1 Incl Over I to 1.0 Incl,. o�.,� DATE Contracto ate r��/t VALIK- ON Over 10 to 50 Incl. NAL V El I am exempt under Sec. I Over 50 to 100 Inc. FINAL d ,B.&P.C.for this reason f Over 100 N ^ Services,Swbd.,MCC&Panelboards � , Z Date: I, 0-200 Amp.Under.600 V' Signature` i 201 - 1000 Amp.Under 600 V 4 ❑ 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 for the following reason(Section 7031.5;Business and'Professions J Additional.Sign Branch Circuits Code): I A70113A El 1;as owner of the property,will do the work and-the structure .I Misc.Conduits&Conductors •� # 0 0 0.o 40 2 is not intended or offered for sale.(Section 7044, Business. Other See GOm-plet Fee Schedule] _ , o -.15 5 0 and Professions Code). r o 0 0 5.5 0 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a.construction.Lending agency, for the , 5 1 .1 8 7 + PERMIT FEE' (Sub=