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Home My Public Portal About5617 ROSEMEAD BLVD_Electrical__ WORKERS COMPENSATION ate of consent to 713001e DPW n2 a APPLICATION FOR ELECTRICAL PERMIT I hereby elirrm that I have a certificate of consent to self mauve leAsa3 or a certificate of Worker a Compensation Insurance or a certified COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV copy thereof(Sao 33000 Lab C) ` 1' I^ f w (1 Po icy,Noble O 2] rItiornpany 'I.Q to r FOR APPLICAIIT TO RLL w ApDRE93 �p I Q- .AIX C4 ❑ Cert10ed copy is hereby furnished New Resdenval Bk1gs 8 Poole NO EACH FEE — 11 11 LOCALITY ❑ Certified copy is Illetl with the county bUtltlirg inspection 1 ut 2 Family SFI •_ .,o department Muth __ 11 Multi family So NEAREST Sq i CROSS ST �—l+/S 4 Date� Applicant [AW1j "LT( M Residential Swimming Pods ASSESSOR YAP ROOK PAGE PARCEL CERTIFICATE OF EXEMPTION FROM WORKERS R OR � COMPENSATION INSURANCE Outlets R. UgMSw o RAI NAPE ty1Uy N14- V O (This section need not be completed If the work Involved by the Fust 20 • a V !!11 T permit Is for one hundred dollars(11/00)or lees) Total No Additional ADDRESS I0'1 ( Co I certlty, that in the performance of the work for which this permit CITY OL,.111< TO W 7,p'� Y is issued I shall not employ any person in any manner so as to become Subject to the Workers Compensation Laws Lighting Fixtures Frail 20PLANC Total No Additional ADDRESS Date Applicant RESIDENTIAL APPLIANCES NOT OVER 3 HP NOTICE TO.APPLICANT If eller meting this Certificate of CITY Tel No Exemption you Should become subject to the Workers Compensation OTHER APPLIANCES NOT OVER 3 HP Provisions of the Labor Code you must forthwith comply with suchMIT fl �l'�)S G Power Apparatus 8 Large Appliances RLIGNT (, provisions or this permit shell be doomed revoked "' ni LICENSED CONTRACTORS DECLARATION Sim 8 Type HLN KW KVA or KVAR ADDRESS (F,Zj V a xA I hereby affirm that I am licensed under provisions of Chapter 9 over 310 101x1 (commencing with Section 7000)of Division 3 of the Business and CITY �aA„ of reg w g) S7 Professmne Code and my license is In lull farce and effect Over 10 to 501nc1 LICENSE OR Over 50 to 1D0Incl REO NUMBER I CW1 G. Over 100 DISTRICT NO P ED BY O License Number 6�.O � O � L.x Class U 11 Services Swbd MCC 8 Panelboerds 0 C� iv Contracts kit Lcw' jTjuf TIAV1 c5L l 0 399 Amp Under 000V FINAL y TateDATE 0 40D 1000 Amp Under 600 V ❑ I am exempt under Sec Over 1000 Amp or Over 600 V V`f VALIDATION W B 8P C for this reason BRANCH CIRCUIT FEESBY Date 15A or 20A 120V 4ghbrg or Recept Z 1 To 10 Branch Circuits Signature11 To 40 Branch Orculb 41 Or More Branch Circuits AC.T. Exemption for Reg Maint Elect 15A 2GA 208V To ZM Sr Orcuib i SINGLE FAMILY Temp Power Pole 8 Appurtenances 3303 41.60 HOME OWNER BUILDER DECLARATION Sign with One Branch Circuit I hereby affirm that I am exempt from the Cordractor a License Law 1 ITEhS for the following reason (Section 7031 5 Business and Professions AddOKstal Sign Branch Circuits Code) TOTAL 42 - 60 ❑ I as owner of the property will do the work and the structure Mist Conduits 8 Conductors C�LK 4� ��( Is not intended or offered for sale (Section 7044 Business Oliver(Sae Complete Fee Schedule) and Professions Code) , (HANG ,L�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 Issued (Sac 3097 PERMIT FEE (Sub Total) OOOO-0001 5/18/44 CIV C) PLAN CHECKING FEE 52f,2 1 AM 9:41 Lender a Name PERMIT ISSUING FEE O'`I Lendar a Address I cerbry,that I have read this application and under penalty of pugury state TOTAL FEE �p that the above Information is correct I agree to comply with all County ordinances and State laws regulating Electrical wining and hereby autfw e representatives of this County to enter upon the above-mentioned property forIrisp cm urpwes SEE REVERSE FOR EXPLANATORY LANGUAGE amNATURE ERNITTEE DA WORKER I haveCOMPENSATION DECLARATION 78AM DPW(12 Bt) APPLICATION FOR ELECTRICAL PERMIT IJ I hereby affirm that I have a certificate of consent to self Insure 7BAse3 or a Certificate of Worker a Compensation Insurance or a certified COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV copy thereof(Sec 3800 Lab C) Policy NO Company FOR APPDCANT TO NLL IN pOORERS ❑ Certified copy Is hereby furnished New Residential Bdgs 8 Peels NO EACH FEE ❑ CoMfied copy is hied with the county building Inspection 1 6 2 Famay Sq Ft — S S LOCALITY _ department Mulfamily Sq FI CRROSEB ST tl Dale Applicant Residential Swimming pools ASSESSOR MAP BOcv( PAGE PAACEL CERTIFICATE OF EXEMPTION FROM WORKERS Outlets Rec —Light_Sw OWNER OR COMPENSATION INSURANCE FIRM NAME (ThisFire io MAIL n perm settlor need not be completed O the work Involved by the Total No Additional ADDRE9a ."O�v 19'�-- permll is for one hundred dollars($100)or lees) I comity that In the performance of the work for which this permit CITY Is Issued I shall not employ any person in any manner so as to PIAN CHECK became sub)ect to the Workers Compensation Laws LlghUng Futures First 20 APpuC � L'I Total No AtltlNOna1 ADDRESS Data Applicant G! NOTICE TO APPLI A T II after making this Certifl le 1 RESIDENTIAL APPLIANCES NOT OVER 3HP CR-y, f7 Tar Exomptlon you should become subject to the Workers Comp eation OTHER APPLIANCES NOT OVER 3 HP Na provisions of the Labor Cotle you must forthwith comply w h such PERkIfT — L _ U provisions or this permit shall be tleemetl revoke Power Apparatus 8 Large Appliances A��ANT LICENSED CONTRACTORS DECLARATION Sine 8 Type HP KW KVA or,KVAR ADDRESS L I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Over 3 to 10 Incl CITY Professions Code and my license Is In full force and effect Over 10 to 50 Ind Over 50 50 to 100(net RED NUMBER 6 c— License Number Q Uc Class t S Over 100 DISTRICT NO q./ ED BY 0 4 Services Swbd MCC d Panelboards O� Q Contractor Date —� ._ / 0 399 Amp Under 800 V 0A 11 ,/ 0 ❑ I em exempt under Sec 400 10DO Amp Under 800 V b� T-q�' VALIDATION W Over 1000 Amp or Over 800 V FINAL d B 6P C for this reason a ABYBRANCH CIRCUIT FEES !q Date 15A or 20A 120V Lighting or Recept Z Signature4 ' 1 To 10 Branch Circuits I l To 40 Branch Caaire ❑ 41 Or More Branch Circuits for Reg Maim Elect ISA 20A 208V To 277V Lighting Br Circuits SINGLE FAMILY Temp Power Pole 8 Appurtenances HOME OWNER BUILDER DECLARATION Sign vnih One Branch Circum t �T''r I hereby affirm that I am exempt from the Contractor a License Lew ,7 � 63.,t' for the following reason (Section 7031 5 Business and Professions Additional Sign Branch Circuits 33 , Code) ❑ Mui Conduits 8 Conductors 1 ITEM I as owner of the property well do the work end the structure 'S A' TAL Is not intended or offered for eels (Section 7044 Business Other(See Complete Fee Schedule)_ , TO63 -405 and Professions Code) CI EK 617 .4 5 CONSTRUCTION LENDING AGENCY CH .G(I I hereby affirm that there le a construction lending agency for the performance of the work for which this permit Is issued (Sec 3097 PERMIT FEE (Sub Total) Civ C) 71 (,H e-7,AJCT Y t4 PLAN CHECKING FEE 6/94 Lenders Nemo I (� ,^'Q `� �n ,�� 5 / PERMIT ISSUING FEE S .I 1 9�4�1 Lander s Address v W ''� I cemlty that I have read le application and under panalry of puRury state TOTAL FEE that the above nnlormebon Is correct I agree to Comply with all 1-aunty ordinances and State laws regulating Electrical wiring antl hereby authonze representatives of this County to enter upon the above-menborned property for Inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE B TUBE OF P ITn:E r M�