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Home My Public Portal About5610-5618 1/2 ROSEMEAD BLVD_Electrical__ TeAeee Gee eA II-eo APPLICATION FOR PEBIIIUT DEPARTMENT OF BUMDING AND SA= COUNTY OF LOS ANGELES ELECTRIC 1 WILLIAM J FOX CHIEF ENGINEER FOR APPLICANT TO FILL IN DISTRICT NO GROUP I ZON]Ep PERMIT NO ELECTRICIAN a dt" 'F'7 ADDRESS Sei. .b �( T R ¢tVQD gY FIRST READY FOR CTION DATA ISSUED (57 Al. TEL COUNTY L BUILDING DDR®S S / Y 41 P PERmn,FFM Aa C NUMBHR EACH FEE LOCALITY T _/� LIGHT OUTLETS CROSS ST �d J� b�� RECEPTACLES WALL SWITCHES OWNER I O'Y� TOTAL OUTLETS SC MAIL 1� QLEC RANGES 2p ADDRESS ELEC HEATERS 25 CITY TEL NO to FIXTURES S 1 HEREBY ACKNOWLED H THAT I HAVE RGD THIS O d MISC APPLICATION AND STATE THAT THE ABOVE IS CORRECT NUMBER OF LIGHT CIRCUITS AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES NUMBER OF RECEPTACLE CIRCUITS AND STATE LAWS REGULATING ELECTRICAL WIRING MOTORS I CERTIFY THAT I FOSSE" THE ABOVE VALID LOS NUMeeR HORSEPOWER ANGELES COUNTY LICENSE OR 1 AM TNBGAL OWNER New MVO HL HP oven INC eACH OF THE RKBIDNTIAROPERTY DESCRIg IAHOVQ I 0 LK" 26 SIGNATURE OF va 2 !O PERMITTH 2 e 1 00 INSP ON RECORD S 16 1 EO 13 60 2 SO So 200 5.00 200 goo 1000 J Soo 1000 1S 00 2 OVER 1000 1 20 00 G M G SET FRED CHANGER-HP O WELDERS AC-KVA GENERATORS•KW ' TRANSFORMERS-"A TEMP MOTORS TO OF ORIG MOVED MOTORS 76 OF ORIG 1 S SIGNS n No NO TRANS APPROVALS O O OAA7K INSPECTOR'S NAME FOR EACH PERMIT CONDUIT WIRING 111 00 WIRING FIXTURES H1 00 t' SUPPLEMENTARY p0 FIXTURES POWER TOTAL FEE UTILITYCO NOTIFIED FINAL 7•A643C-E•8061311/72 APPLICATION FOR ELECTRICAL PERMIT , BUILDIN ND SAFETY D BION FOR APPLICANT TO PILL iNJOB L10/ O New Residential Bldgs &Pool• EACH NO FEE ADDRESS J 1 &2 Fmwly Sq Ft $ - $ LOCALITY r�2.•7 c" Multi family Sq Ft _ NEAREST CROSS ST Residential Swimming Pools OWNER OR �(/, FIRM NAME 1 se Outlets Light Switch&Receptacle MAD ADDRESS Q fda �b First io /9 °D el No � 33 /f Additional � � CITY PLAN CHECK Lighting Fixtures; ° APPLICANT R4)) G/ mIpdNdft Tl First 20 ADDRESS S 0 S R-711-N74,C, Additional CITY 4N. /WUOC Tel No 4 4,9 3 Fixed Appliances Not Over 1 HP APP MIT PPS/ �e/ gi (=017S4, %1 Range_ Heater_ DW ADDRESS Q �, /e��,L Oven _ Dryer W M _ Top _ FAU WH _ CITY tO- CaOO4 Tel No �1 / QQ3 Hood Fan LICENSE OR Disp A C / REG NUMBER O` Clesa o U van THIS wPPucwnon COwn(CT A1410 AOR.I TO COMPLY O Power Apparatus& Large AppliancesWITH ALL CO UHTYSOiSASCa• An. .TATS LAWS eaGULATinu Size&Type HP, KW, KVA,or KVAR LCCTRICAL"'RING iy I Up to 1 Incl i "MASSY CORTIPY T w Pne PaRLY n GUT....Aeoioe = Over 1 to 10 Incl LICaN.aG w. RKOVIR.O a LO.w Laa c TAT. G _ Over 10 to 50 Intl caccie cO NcalOc rLcoAL OWHOR TOCK TNa Aaovx Over 50 to 1001nt1 PERMiTEE Over 100 SIGNATURE DISTRICT NO RO SSE V Services Q 0 200 Amp Under 600 V 201 1000 Amp Under 600 V APPROVALS DATE _!SG S NCTOR Over 1000 Amp or Over 600 V SIGNATURE TEMP POWER POLE Temp Power Pole&Appurtenances UNDERSLAB WORK Sign with One Branch Circuit Additional Sign Branch Circuits ROUGH CONDUIT (Other) WIRING FIXTURES POWER AUTHORIZED PERMIT FEE (Sub Total) UTILITYCO NOTIFIED PLAN CHECKING FEE (One Fourth Permit Feel FINAL PERMIT ISSUING FEE NOTES TOTAL FEE PLAN CHECK VALIDATION CK MO CASH PERWHY-VALIDATION CK MID CASH 9 3 0�tUy 2 2 D 1 5.4 0 •=b WORKERS COMPENSATION DECLARATION IJ0a19DPJ/3/V APPLICATION FOR ELECTRICAL PERMIT O e mi I hereby affirm that I have a certificate of consent to self a.apyD mature 'or a cem,ficate of Worker,' C.mpensqRion Insurance COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS or a certfied co y thereof(Sec 380, La nyL�JI No Company FOR APPDCAW TO RLL IN JOB �^"y` Certified copy is hereby furnished New Residential Bldgs &Pools EACH NO FEE ADDRESS 61 Certified copy is filed with the coun bmldmg in 1 & 2-Family Sq Ft $ — $ LOCALITY hon department Multifamily Sq Ft NEAREST �� Residential Swimmy Pools CROSS ST �h Date-1��--` Applicant WNER FFIIRM NAME LL AIA CERTIFICATE EXEMPTION FROM RKE Outlets Re Light w MAIL COMPENSATION INSURAN r� � all. /V Finn 20 (This sedlon need not be completed If the work Involved by Total No Additional CITY Z�- .TeF No the Permit Is for one hundred dollars($100)or less) 17 PLAN KK I certify that in ,he performance of the work for which this APPLICANT Qi permit is issued I shall not employ any person in any manner Li titin Futures Fust 20 ADDRESS so as to become subject to the Workers Compensation Laws g g Total No '0`�'t'°nal Date Applicant CITYIL el No _ NOTICE TO APPLICANT If after making this Certificate of Fixed Appliances Not Over 1 HP PERMIT Exemption, you should become subject to the Workers Range— Heater—DW — APPLICATION Compensation provisions of the Labor Code, you must forth Oven — Dryer —W M — ADDRESS with comply with such provisions or this permit shall be Top — FAU _WH — deemed revoked Hood _ Fan —Other_ CITY Tel No LICENSED CONTRACTORS DECLARATION Disp ` Room Air Cond — LICENSE OR Class hereby affirm that I am licensed under provisions of Chapter 9 REG NUMBER Jq (commencing with Section 7000)of Division 3 of the Business Power Apparatus 8 Large Appliances DISTE NO p y >_and Profs ons Code,and my license is in full force and effect d Size 8 Type HP, KW, KVA, or KVAR 0 License Number Uc Class U Up to 1 Incl FINAL fys� Contractor Dote Over 1 to 10 Incl DATE "5 A v VALIDATION ¢O ❑ Over 10 to 50 Incl FINAL lk- I am exempt under Sec Over 50 to 100 Inc BY W B&P C for this reason Over 100 LU N Date Services, Swbd MCC 8 Ponelboards Z 0- 200 Amp Under 600 V Signature 201 - 1000 Amp Under 600 V ❑ Exemption for Reg MaiOver IODD Amp w Over 600 V Maim Elect SINGLE FAMILY Temp Power Pole 8 Appurtenances HOME OWNER-BUILDER DECLARATION a I hereby affirm that I am exempt from the Contractor i License Sign with One Branch Circuit ACCT.. Low for the following reason (Section 7031 5, Business and Additional Sign Branch Circuits 3307 34,50 Professions Cade) 1 ITEMS ❑ I as owner of the property, will do the work and the Mnc Conduits 8 Conductors structure is not intended w offered forsale(Section 7044 Other (See Complete Fee Schedule)_ , TOTAL 34 .250 Business and Professions Cade) CHECK 50 CONSTRUCTION LENDING AGENCY I hereby affirm that there iso construction lending agency for C+W4Z •00 the performance of the work for which this permit is issued PERMIT FEE (Sub Total) (Sec 3097 Civ C ) PLAN CHECKING FEE 0000-0001 lU 6/1.19 Lenders Name PERMIT ISSUING FEE + bW 1 AM10-58 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 County ordinances and State jaws regulating Electrical wiring, and hereby authorize representat ves of this County,to enter upon the ob a mentioned pop ty for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of P&.1"71", mine Dote ms RKEthat I hPI:TISATIONDECLARATION a806 APPLICATION FOR ELECTRICAL PERMIT I he�eLiy a rm that I have a certificate of consent to sell ��' mst7r a certificate of Workers' Compensation Insurance COUNTY OF LOS ANGELES BUILDING AND SAFETY -ar u cS�fied copy thereof (Sec 3800 Lab F ) If Policy IW 0112"Comport FOR APPLICANT TO FILL LN JOB Certified copy is hereby furnished New Residential Bldgs 8 Pools EACH NO FEE ADDRESS Certified copy is filed with the county building mspec 1 8 2-Family Sq Ft f — f LOCALITY hon department Multi-family Sq Ft — NEAREST // Residential Swimming Pools CROSS ST Date $7—Applicantl/�� OWNER OR FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS Outlets Rec_Light_Sw_ MAIL COMPENSATION INSURANCE First 20 ADDRESS (This stolon need not be completed If the work Involved by Total No Additional ' CITY Q r Tel No 'Z$'. the permit Is for one hundred dollars($100)or less ) I certify that in the performance of the work for which this gPIAAN CCgj CK permit 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 Date Applicant CITY _ Te) No NOTICE TO APPLICANT If, after making this Certificate of Fixed Appliances Not Over I HP PERMIT Exemption you should become subject to the Workers Range_ Heater_D W _ APRICAM Compensation provisions of the Labor Code you must forth Oven _ Dryer —W M — ADDRESS with comply with such provisions or this permit shall be Top FAU —W H — deemed revoked CITY _ Te LICENSED CONTRACTORS DECLARATION Hood — Fan _Other_ l N hereby affirm that Disp _ Room Air Cond LICENSE OR am licensed under provisions of Chapter 9 REG NUMBER Z ZT (commencing with Semon 7000) of Division 3 of the BusinessDISTRICT NO PROC BY IL and Professions Code and my license is in full force and effect Power Apparatus 8 Large Appliances 0 r�� '/�7 Size 8 Type HP KW KVA or KVAR ✓s License Num/Ib--er Z_ 5Z7`/ Lic CIO.Ari, to I Incl 1 FINAL V Contracto�dl� �fa� ate Over I to 10 Incl DATE — / VALID ON 0 ❑ Over 10 to 50 Incl FINAL V I am exempt under Sec Over 50 to 100 Inc BY U B 8P C for this reason Over 100 & Date Services, Swbd MCC 8 Panelboords Z 0 -200 Amp Under 600 V Signature 201 - 1000 Amp Under 600 V ❑ Exemption for Rag Maint Elect Over 1000 Amp or Over 600 V 7 6 7.2 A SINGLE FAMILY Tamp Power Pole 8 Appurtenan e� F # e e e it's 2 HOME OWNER BUILDER DECLARATION Sign with One Branch GrcwI -aW/ s s I hereby affirm that I am exempt from the Contractor s License I 4 0 5 0 Law for the following reason (Section 7031 5 Business and Additional Sign Branch Circuits Professions Code) s it e 4 Q 5 0 E I as owner of the prwill do the work and the structure is not intendedded or Misc Conduits 8 Conductors or offered for sole (Section Other (Sae Complete Fee Schedule)_ ► 0 al 4 --87 704 Business and Professions Code) CONSTRUCTION LENDING AGENCY I hereby affirm that there is o 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 PERMIT ISSUING FEE Lender s Address I certify that I have read this application and state that the TOTAL FEE a above information is corre0 I agree to comply with all County ordinances and State laws regulating Electrical wiring and hereby authorize representatives of this County to enter upon 'he abgve-mentione roperty for/inspection p r�- JrJSt he oa/(�J — SEE REVERSE FOR EXPLANATORY LANGUAGE g tura of Per m e t t >.1 • WORKat I vas a celtATION DECLARATION 79Aa06 ,D/a, APPLICATION FOR ELECTRICAL PERMIT I hereby aHrtm that I have a certdcdte d consent to sell insure �eaeO I I or a certificate of Workers Compensation Insurance or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY ILJI copy thereof(Sec 3800 Lab it;) _..M. NDPolicy No C, mpany ZFON APPLICANT TO FILL IN JOB ❑ Carbfed copy a hereby furnished New Residential Bldgs 8 Pods EACH NO FEE ADDRESS — LOCALITY Certif py Is Bled with the county 6 iMJuq inspection 1 8 2-Family Sq Ft S — S t � Multi-femilY SQ FI NEAREST CROSS ST Date Applicant/} Residentel Swimming Pods ' OwNER oR FSiM NAA£ CE FICATE OF EXEMPTION FROM WORKERS Outlets Rec—Light — Sw ANL COMPENSATION INSURANCE ADDRESS perk M rrvdFirst 20 onsection need not be completed 0) eese work Ived by the Total No Additional CITY Tel No permit u for e hundred tlolleu($100)or l 1 I certify Mat in the performance of the work for which the permit PLAN CHECK APP CANT issuedsued shall not empty arty moaperson N any manner so as to b become subject to the Workers Campensetron Laws Lighting Factures First 20 ADDRESS Total No 'Additional CITY Tel No Date Applx;ant Fixed Appliances Not Over 1 HP PERMIT NOTICE TO APPLICANT If after making this Certificate Of Exemption you should became subAct to the Workers Compensation Range_ Heater_ DW _ APPLICANT pwsns of the Labor Code you must fortinmth comply with such Oven _ Dryer _ W M _ ADDRESS rco provisions or this permit shall be deemed revoked Top — FAU _ WH _ LICENSED CONTRACTORS DECLARATION Hood _ Fen _ OtherCITY Tel N _ I hereby affirm that I am licensed under prwrecons of Chapter 9LICE OR (commencing with Section 7000)of Division 3 of the Business and DisP Roam Cond REO NUMBERZf C1M& Professions Code,and Try license u in full force and effect Power Apparatus 8 Large Appleroes aSiRlM No PROLE � Size 8 Type HP KW KVA or KVAR a License Number Lc Class Lip to 1 Incl FINAL Over 1 to 10 Inc] DATE T1 Cont—t-4- Date Over 10 to 50 Incl ❑ I am exempt under Sec Over 50 to 100 Inc FINAL BY BBPC for the reason Over 100 Services Swbd MCC It Panelboards , N 0- 200 Amp Under 600 V Z Signature 201 - 1000 Aran Under 600 V ❑ Over 1000 Amp or Over BOO V 9 9 2 2 A Exemption for Reg Marta Elect SINGLE FAMILY Temp Power Pole 8 Appurtenances # • • • • • 2 HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit I hereby affirm that I am exempt from the Contractors License LawA�drorel Sign Branch Grcote • • 2 5 50 for the fdloaug reason(Sector 7031 5 Business and Profaleiom code) • • • 255075 ❑ I as owner of the property will do the work and the structure a Other See Complete Fee Schedule) o617-88 MM Corlduils 8 Coiductors _ ► e not interred offered for eels (Section 7044 Business ( and Professions Code) CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permlt is esuad(Sec 3097 PERMIT FEE (Sub-Total) Cry C) RAN CHECKING FEE Lenders Name PERMIT ISSUING FEE Lenders Address I certify that I have read the application) and state that the above TOTAL FEE information a correct I agree to comply with all County ordinances and State k regulating Electncal wrong end he y uthorae rape res this Cou y enter upon the toned party for ctcn pu SEE REVERSE FOR EXPLANATORY LANGUAGE nature f rmittee WORKERS have a certificate o consent to 711A8D6 ,D,a, APPLICATION FOR ELECTRICAL PERMIT I hereby affirm that I have a eeftillCate of consent to self insure �eOeO or a certificate of Workers Compensahon Insurance or a carMied COUNTY OF LOS ANGELES BUILDING AND SAFETY copy thereof (Sec 3800 lab C) p Polity No rZ4'a i11� Company�Rc FOR APPLICANT TO FILL IN JOB ❑ Certified copy a hereby furmshad New Residential Burps 8 Pods EACH NO FEE ADDRESS v ❑ Certified copy a filed with the county building inspection 1 d 2-Family So Ft $ — $ LOCALITY department Mufti-famllY So Ft NEAREST CROSS q p� Residential Swimming Pools OWNER ST Date/1�'.L1�-- Apdoarrt ly FIRM NAME CERTIFICATE OF EXEMPTION FROM WOR RS Outlets Rec_Light _ Sw COMPENSATION INSURANCE ADDRESS (This section head not be completed If the work Involved by the Feat 20 CITU Tel No permit Is for ors,hundred dollars($100)or leas) Total No Additional �6 I certify that in the performance of the work for which this perms PtnN APPLICANT is Issued, I shall not employ ary person in any manner so as to become subject to the Workers Compensaton Larva Lighting Fudures First 20 ADDRESS Total No Additional CITY Tel No Date Applicant Fixed Appliances Not Over 1 HP PERN4T NOTICE TO APPLICANT If after making this Certificate d Exemption,you should become subject to the Workers Compensation Range— Heater— DW — APP NT provisions of the tabor Code you most forthwith comply with such Oven _ Dryer _ W M — ADDRESS provlsoms or this permit shall be deemed revoked Top — FAU — WH — LICENSED CONTRACTORS DECLARATIONFood — Fan — Other— CITY Td No Rof I hereby affirm that I am licensed under provisions of Chapter 9 sp - LICENSE OF (commencing vnth Section 7000) of DNeion 3 of the Business and Di Raam Nr Cond REO NLOAMR 6 Z Clave Professkms Code and my license is In full force and effectDISTRICT NO PROCESSED BY Power Apparatus& Large Appliances {D7 Sae 8 Type HP,KW KVA or KVAR License Number J Lc Glass�'`�� Up to 1 Irci DATE p Over Ito 10lncl DATE 3 VALIDATION Contractor Date/� �—?Q Over 10 to 50 Incl E] ntFINALL I am exempt under Over 50 to 100 Inc BY r 11.1 B BPC for this reason Over 100 N Services Swbd MCC 8 Panelboards ? Date 0-200 Amp Under 600 V r� Signature 201 - 1000 Amp Under 600 V over 1000 Amp or Over 600 V # . . e e e 2 ❑ Exemption for Rep Ment Electv SINGLE FAMILY Temp Power Pole 8 Appurtenances # e 2 HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit ITCT I f # • 2 1 hereby affirm that I am exempt from the Contractors License Law for the following reason (Section 7031 5 Business and Professions Additional Sign Branch Circuits # Code) 2 ❑ I as owner of the Misc Conduits d Conductors # a e e ' 2 property or do the(Section and the Buss re Other (See Complete Fee Schedule) e net intended or offered far sale (Sacmn 7044 Business ► and 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(Sac 3097 PERMIT FEE (Sub-Total) CW C) 1 I PLAN CHECKING FEE Lenders Nam /1 r YL J v�� PERMIT ISSUING FEE Q larders hat I he '7Olf /1 I certify that I have read lyre appllcetxrl end state thatIke shove TOTAL FEE idormaton 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 sir i pedon sea SEE REVERSE FOR EXPLANATORY LANGUAGE Signature itteq vDate i WORKERSCOMPENSATION DECLARATION 76A663 10/81 I hereby affirm that I have a certificate of consent to self insure, CE-6066 APPLICATION FOR ELECTRICAL PERMIT 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. i- ` •' 'J Company _, i FOR APPLICANT TO FILL IN JOB ❑ Certified copy is hereby furnished. New Residential Bldgs.&Pools EACH NO. FEE ADDRESS Certified copy is filed with the county boinspection 1 & 2-Family,Sq.Ft. $ _ $ LOCALITY department. '.'._9_.,,.y'''. ` Multi-family Sq.Ft. GROSSSST. Date /J Applicant T-'!-•7.�' ,/ Residential Swimming Pools OWNER OR ~ 7 FIRM NAME n 'l CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Sw. Rao— Light 1 MAIL + COMPENSATION INSURANCE �— ' 1 / ADDRESS ' (This section need not be completed if the work Involved by the First 20 permit is for one hundred dollars($100)or less.) Total No. Atlditional CITY / y::'�- y Tel.No. 1 certify that in the performance of the work for which this permit LAP jC E 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 f ADDRESS _. / Total No. r CITY _f Tel.No. Date Applicant Fixed Appliances Not Over 1 HP Additional CITY NOTICE TO APPLICANT: It, after making this Certificate of + PER 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.— ADDRESS provisions or this permit shall be deemed revoked. Top — FAU _ W.H. If LICENSED CONTRACTORS DECLARATION Hood _ Fan _ Other_ CITY Tel.No. I hereby affirm that I am licensed undo, provisions of Chapter 9Cond. LICENSE OR (commencing with Section 7000) of Division 3 of the Business and Disp. — Room Air REG.NUMBER / Class. }- Professions Code,and my license is in full force and effectPower Apparatus&Large Appliances DISTRICT NO. PROCESSED BY 0 - U Size& Type HP,KW,KVA,or KVAR _r W License Number Lia Class Up to 1 Incl FINAL -t Over Ito 10 Incl. DATE VALIDATION W Contractor Date Over 10 to 50 Incl. FINAL ❑ I am exempt under Sec. - Over 50 to 100 Inc. By B.&P.C.for this reason Over 100 d Services,Swbd.,MCC& Panelboards Date: 0-200 Amp.Under 600 V f,P, W Signature 201 - 1000 Amp.11nder 600 V ❑ Over 1000 Amp.or Over 600 V - • ,• e, ^ • w• Exemption for Reg.Maint.Elect. SINGLE FAMILY Temp. Power Pole& Appurtenances 'I "• ',• "'"" HOME OWNER-BUILDER DECLARATION Sign with One Branch'Circuit • • • , 111"y affirm that I am exempt from the Contractor's License Law Additional Sign Branc!4Circuits for the following reason(Section 7031.5,Business and Professions Code): ❑ I,as owner of the property,will do the work and the structure Misc.Conduits &Conductors is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) ► and 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 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 iRsp2 An ses. rs' SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date n- WORKERS' COMPENSATION DECLARATION 76-883 10/81 APPLICATION FOR ELECTRICAL PERMIT I hereby affirm that I have a certificate of consent to self insure, CE-Boat or a certificate of Workers Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY copy thereof (Sec. 38001ab. O) Policy No. .. Company 1 .--- I FOR APPLICANT TO FILL IN JOB ", I ❑ Certified copy is hereby furnished. New Residential Bldgs.& Pools EACH NO. FEE A11RE3S •� - - ❑ 1 & 2-Family, Sq.Ft. $ _ $ LOCALITY Certified copy is filed with the county building inspection department Multi-family Sq.Ft. NEAREST GROSS ST - - Residential Swimming Pools OWNER OR Dater. : Applicant � "'•. t FIflM NAME ) - CERTIFICATE OF EXEMPTION FROM WORKERS' MAIL COMPENSATION INSURANCE Outlets:Rec_ Light Sw. gDOREBS /• ` ' tl (This section need not be completed N the work involved by the First 20 permit is for one hundred dollars($100)or less.) Total No. Additional CITY 'r _ Tel.No. I certify that in the performance of the work for which this permit PLAN CHECK m 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 APPUCAM "t ,r //H ) 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 provisions or this permit shall be domed revoked. Top FAU W.H. LICENSED CONTRACTORS DECLARATION Hood — Fan _ Other_ CITY 7' ). y.. Tel.No,. 1 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 / G. Professions Code,and my license is in full force and effect. DISTRICT NO. PROCESSED By Power Apparatus&Large Appliances U f _ Size& Type HP,KW,KVA,or KVAR - W License Number - c Lie.Glass ` `" Up to 1 Incl. FINAL --1 I Over 1 to 10 Incl. DATE VALIDATION Contractor Date Over 10 to SO Incl. FINAL ❑ I am exempt under Sec. Over 50 to 100 Inc. BY BAP.C.for this reason Over 100 ^_ Services,Swbd.,MCC& PanaR lboards , Date:— 0-200 Amp.Under 600 V W Signature 201 - 1000 Amp.Under 600 V y--`',ipj., F� j Over 1000 Amp.or Over 600 V ❑ Exemption for Reg.M16int.Elect • • ` ' A. SINGLE FAMILY Temp.Power Pole& Appurtenances - „• • '• ' I, HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit If I hereby affirm that I am exempt from the Contractor's License Law • • • for the following reason(Section 7031.5,Business and Professions Additional Sign Branch Circuits Code), El 1, Conduits& Conductors I,as owner of the property,will do the work and the structure •' v • • _' is intended or for sale (Section 7044, Business Other(See Complete Fee Schedule) f- I andd P Professions Code).de). 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. GJ. , I! PLAN CHECKING FEE I Lender's Name _ j.-; L/ l- '- - - PERMIT ISSUING FEE Lender's Address I certify that I have mad this application and state that the above TOTAL FEE -. r information is correct. I agree to comply with all County ordinances and State laws regulating Electrical wiring, and hereby authorize j representatives of this County to enter upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signatudf Pormittee - Date re L S COMPENSATION DECLARATION 7 a to/at n ) 'I have`a certdrmte of consent to Sall mere, APPLICATION FOR ELECTRICAL PERMIT IILJII i ,atnM Workers Compensation InsurancB or a cemhed COUNTY OF LOS ANGELES BUILDING AND SAFETY oro �.-_ ,�.��,)eat(Jac 3800 Lab C) Ip Cpmpenyl R J JV�T FOR APPLICANT TO FILL IN . JOB ESS Candled copy is hereby furmshed Now Resdenbal Bldgs &Pods EACH NO FEE ADDR / 1 & 2-Family Sq Ft S — S LOCAUTV _ Certified copy s fllotl with the my dd' Inspactwn NEAREST 41 department Muf11-family Sq Ft CROSS ST / Date Resdermal Swimming Poolst pYfER OR � 'I.pM lL1L ��`-.;} ��\ FIRM NAME r CERTIFICATE OF EXEMPTION FR WORKERS Outlets Rec Sw,_ - �� \t MAILffAMAI COMPENSATION INSURANCE D ADDS (This section need not be completed It the work Imalmd by the Fust 20 '}J CITY , Tel No permit Is for one hundred dollars ($100)or leen) Total No Pdtld anal - - PLAN Ed I candy That in the Performance of the work fpr which this permit � Af9L1CANT Is issued 1 shall not employ any person in say manner so as to become subject to the Workers Cartpermalbon Laws Lighting Fixtures Q First 20 ADDRESS Total NoAdd�� - CITY Tel No Date Applicant Fixed Appharpes Not Over 1 HP PFRMfT NOTICE TO APPLICANT If after making this -Certdlcate of APPtK:Af1T Exemption you shoud become subject to the Workers Compensation Range— Heater— DW pmvivons of the Labor Code you must forthwith comply with such Oven — Dryer — W M ADDRE .# pronscns or this permit shell be deemed revoked ( - Top —.FAU —W H - - - - - - - UCENSED CONTRACTORS DECLARATION r CITU Tel NoL Hootl — Fan Other_ I hereby affirm that I am licensed under provsors of Chapter 9 -.� Room Air Cond- --- - - -- - _ UCEN OR,- : ;, i7_- Cwa� (commencing with Section 7000) of Divscn 3 of the Business and '- REO NUMBER !i L+ Prolesspns Code and my license in full force and effect _ Power Apparatus 8 Large Appliances-- Day S¢e &Type HP KW KVN or KVAR License Number�� •� Uc Class-�= lb[0 1 Incl- _ - _ FINAL Over 1 to 101nd __ DATE _./ -VALIDATION__ Contract Defe Over 10 to 50 Ind Fl U ❑ 1 am exapt uner Sac - Over 50 to 100 Inc 8 8 0 2 over 100 d BBPC lois [h6 reason _ N Services Swbd MCC& Panelboards - - - S- �- - - -- - # . i • 2 Z Date 0- 200 Amp Under 600 V e+ Signature -- 201 - 1000 Amp Under 600 V - 1 - (494,50 ❑ - Over 1000 Amp or Over 600 V - s Ale Exemption for Reg Maint Elect / • • 4 9 & 5 0 � SINGLE FAMILY Temp Power Pole&Appurtenances _ __ _ - 01 1 9-8 8 HOME OWNER-BUILDER DECLARATION Sign with One Branch Clmulf I hereby affirm that 1 am exenpt from the Contractors License Law Addrtlpnal Sign Branch Circuits - for the following reason(Section 7031 5 Business and Professions Code) ❑ Misc Conduits 6 Conductors I as owner de Busine the property will do the work and the Busmass - s not intended or offered for sale (Section 7044 ss Oster(See Complete Fee Schedule) and Professions Code) CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the nerlormance of the work for which this permit is issued(Sac 3097 PERMIT FEE (Sub-Total) Civ C) PLAN CHECKING FEE Lenders Name PERMIT ISSUING FEE (/ Lender s Address I,Certdi that I have read This application and state that the above TOTAL FEE irmahon rc correct 1 agree to comply with all County ordinances tate aws regNahng Elecincal wiring and hereby authorae atives the County to enter upon the above-nentoned s eclio� purposes �t <7 - SEE REVERSE FOR EXPLANATORY LANGUAGE