HomeMy Public PortalAbout5620 ROSEMEAD BLVD_Electrical__ WOR"hI ERICOMPENSATION DECLARATION 76A663 40/81
I°'a' APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that have a certificate of consent to self insure,
V or a certificate of Workers' Compensation Insurance,or a certified 1 COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof)Se
c.3800.Lab.C.)
Policy No. 12 2 Company S A 4 C+C �• FOR APPLICANT TO FILL IN JOB _
❑ Certified copy is hereby furnished. New Residential Bldgs.&Pools EACH NO. FEE ADDRESS , ' tr S-0S c•M
is filed with the count building inspection — LOOALITY —
Certified copy y 9 p 1 &2-Family,Sq.Ft.. $ — $ G=p4?�(►' R`7 1�
department. r Multi-family Sq.Ft. NEAREST 1
Residential Swimming Pools CROSS ST. �. i a J
Date 2Z Ir Applicant �'�'L' S+6 �n Q�T '} OWNER
OR-FIjit (, -Z, r
CERTIFICATE OF EXEMPTION FROM WORKERS' MAIL'
Outlets: ec—Light_Sw.— � v V
COMPENSATION INSURANCE ADDRESS .!i 3 ° �` d
(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. Additional CITY�t�S 1S� C. iti Tel.No. aG,F P3
PLAN CHECK
I certify that in the performance of the work for which this permit I APPLICANT A •P.C- S, 6 a a.
is issued, I shall not employ any person in any mannet so as to
become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS/ �� Z y S (= G A 12
I Additional
Total No. CITY f ( Tel.No.
Date. Applicant ' JS A V I W 1 N +d a/� 5Wa-6 63/
NOTICE TO APPLICANT: If, after making this Certificate of Fixed Appliances Not Over 1 HP PERMIT
APPLICANT S /Z 9-t N
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 deemed revoked.. Top FAU _ W.H.
CITY Tel.No.
LICENSED CONTRACTORS DECLARATION Hood Fan. _ Other_
I hereby affirm that I am licensed under provisions of Chapter 9LICENSE 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. DISTRICT NO. PROCESSED BX
Power App aratus&Large Appliances
_ Size I Type HP,KW,KVA,or KVAR V '�
License Number 3 �SS uc.Class �' S Up to 1 Incl. FINAL V
l� 1��^ S• 1-4 6 R1 TJ`3 C I Over 1 to 10 Incl. DATE O
Contractor Date ' �-L' F I VALID ON
❑ I Over 10 to 50 Incl. FINAL
I am exempt under Sec. Over 50 to 100 Inc. BY I M
B.&P.C.for this reason Over 100 p„
Services,Swbd.,MCC&Panelboards N
Z
Date: 0-200 Amp.Under 600 V
Signature 201 -',1000 Amp.Under 600 V
❑ Over 1000 Amp.or Over 600 V
Exemption for Reg.Maint.Elect. I
SINGLE FAMILY Temp.Power Pole&Appurtenances 8 8 3.7 A
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit / jL1—Pei
I hereby affirm that I am exempt from the Contractor's License Law Additional Sign Branch Circuits ) # 0 0 0 0.0 2
for the following reason(Section 7031.5,Business and Professions
Code): 1003550
❑ Misc.Conduits&Conductors I
1,as owner of the property,will do the work and the structure
is not intended or offered for sale (Section 7044, Business Other. (Se o 0055505:
Complete Fee Schedule) _ ;
and Professions Code). T 0
1,25-88 2pp
CONSTRUCTION LENDING AGENCY I
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 570
Lender's Address
1 certify that I have read this application and state that the above TOTAL FEE � TO I
information is correct.I agree to comply with all County ordinances I
and State laws regulating Electrical wiring, and hereby authorize l
representatives of this County to enter upon the above-mentioned
�gns�tu. ermittee ��
rty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Date
APPLICATION `FOIA E_ LEC,'Fdl PE.6�IVI9T 1
-COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER- BUILDING
BUILDING AND SAFETY DIVISION ADDRESS z 2jo
JOHN A. L.AMBIE. COUNTY ENGINEER _
WILLIAM A.JENSEN.SUPT OF BUILDING LOCALITY
FOR APPLICANT TO FILL 1N NEAREST' C
PFJWT FEES CROSS ST.
-ITEM NUMBER I EACH FEE OWNER
OUTLET$: $ $ MAIL
tlGHrs RECEPT. SW. '2r f0 ADDRESS.
LIGHTING.FIXTURES f 10• CITY TEL.NO.
ELEC.RANGES, : CLO.DRYERS ' ELECTR CIAN
WATER' H E.A TA R S .50
ADDRESS-3-.2
ELEC.SPACE HTRS: -DISHWASHERS.
CITY y'YG' TEL.NO. . Z S�
GARBAGE.DISPOSERS AUTO.- STATE
WASHERS 'STA.COOKING UNITS .25 LICENSE NO.. -100
fR
MOTORS: OVER ' INC H.P. {DISTRICTNO. GROUP ZONE ' EY
.25
y56, INSPECTION RECORD
1.0
1.80 •�4 '!/.f�7' (_7 IC�/G� I�
Is 50: 2:80 `
`
50^-200 5.00 "/ / /'� f�'°�.-�
NO.TRANS. '1 `� 'W!. � !Q ,G-�, 1 4✓J e
SIGNS: per';
r• 1
• NO:LAMPS S�' - �JI'ird v •GJ�j'/ �
`
SERVICE C-600V ,��.s' 1.00
SERVICE OVER 800V 5.00 ►- c''.
r �.��,�i t g w ,�•G.'rr'�I
WIRING PERMIT 1.00 �� �t®�� ✓� �-'
FIXTURE PERMIT 1.00 QU " wa Eg9-�Q►�r�w
SUPPLEMENTARY PERMIT' .SO .� }�� .1 j•
TOTAL FEE
I HEREBY ACKNOWLEDGE THAT 1 HAVE.READ THIS APPLICATION APPROVALS DATE INSPECTOR'S SIGNATURE
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY - -
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING 'CONDUIT
ELECTRICAL WIRING. WIRING -
I HEREBY CERTIFY THATED. I AM PROPERLY REGISTERAND&R
LICENSED AS REQUIRED. 13Y LOS ANGELES COUNTY AND STATE,OF FIXTURES
CALIFORNIA. OR THAT-1. AM THE.LEGAI.POWNER OF THE ABOVE ...
DESCRIBED RESIDENT c POWER
SIGNATURE UTILITY CO.NOTIFIED
OF PERMITTE
FINAL }/
ap ATION �uPERYISINUR G EEECTRICAL ENGINEER
CK MO I CASH -
�. l04856 :::8 APR 4 2 D - .G0 10