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Home My Public Portal About5721-5747 ROSEMEAD BLVD_Electrical__ WORKERS'COMPENSATION DECLARATION ' 20-W19 DPW 3/87 I- s• I-Rg�eiy affirm that I have a certificate of consent to self C, APPLICATION FOR. ELECTRICAL PERMIT Q insure, or a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES il• DEPT. OF PUBLIC WORKS 1 or a certified copy thereof(Sec. 3800, Lab. C.) Policy No. Company FOR APPLICANT TO FILL IN ;,JOB ❑ 21 —5 424-1 gysFwAv Certified copy is hereby furnished. New Residential Bldgs. &Pools EACH NO. FEE ADDRESS ' ❑Certified copy is filed with the county building inspec-� 1 &2-Family, Sq. Et. LOCALITY$ '— $ IE ' tion department. Multi-family Sq. Ft. -- (NEAREST w ,�, ' ;.CROSS ST. A Date Applicant Residential Swimming Pools OWNER OR I FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' I Outlets: Rec Light Sw._ MAIL COMPENSATION INSURANCE bADDRESS (� This section.need not be. om b First 20 ( cPleted If the work involved y' Total No. Additional CITY Tel. No: the.permit is'for one hundred dollars(;100)or less.) i PLAN CH I certify that in the performance of the work for which this - MK APPLICANT /J 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 ALve Additional Date. Applicant. Total No. CITY 14fTel No. . NOTICE TO APPLICANT: If., after making this Certificate of 1' Fixed Appliances Not Over 1 HP PERMIT Exemption, you should become subject to the Workers' I Range— Heater—D.W. APPLICATION Compensation provisions of the Labor Code, you must forth- I Oven — Dryer —W.M._ 'ADDRESS with comply with such provisions or this permit shall be ' Top — FAU —W.H. — deemed revoked. Hood — Fan —Other_ CITY Tel. No. LICENSED CONTRACTORS DECLARATION DisP• ._ Room Air Cond. — LICENSE OR I hereby affirm that I am licensed under.provisions of Chapter 9 ' REG.NUMBER Class. (commencing with Section.7000)of Division 3 of the Business Power.Apparatus&Large Appliances DISTRICT NO. PRESSED BY and Professions Code,and my license is in full force and effect. I Il I. Size&Type HP, KW, KVA, or KVAR1•.�7 � U License Number ,. .Lic. Class I' Up to 1 Incl. FINAL ..,- .. DATE ,,t; T j;}�f1-: — ver 1 to 10 Incl. VALIDATION 6 Contractor Date ver 10 to 50 Incl. FINAL ��i b' V ❑ I am exempt-under Sec, j.. Over 50 to 100 Inc. BY , i I#Asir 4 76 _Ow,. B.&P.C. for-this reason Over 100 fid Date: Services, Swbd., MCC 8 Parielboards ti•Ilt•!. s 0-200 Amp. Under 600 V , I-�i i ;i� - Signature I� 201 - 1000 Amp. Under 600 V ❑ Over 1000 Amp. or Over 600 V Exemption for Reg..Maint. Elect: SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Temp. Power Pole&Appurtenances1rs r. £� I hereby affirm that I am exempt from the Contractor's License I; Sign with One Branch Circuit + 931 1 s ri D'i Law for-the following reason (Section 7031.5, Business and I Additional Sign Branch Circuits Professions Code): ❑ I, as owner of the property, will do the work and the (Mist. Conduits&Conductors fl structure is not intended or offered for sale(Section 7044,' Other(See Complete Fee Schedule)_ Business and Professions Code). CONSTRUCTION LENDING AGENCY 1i I hereby affirm that there is a constructi6n lending agency for �. the performance of the work for which this permit is issued Ij PERMITTEE (Sub-Total) .(Sec. 3097, Civ. C.). i' 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 I above information is correct. I agree to comply with all County ordinances and State laws regulating Electrical wiring, andu/L�/�� hereby authorize representatives of this County to enter upon 'the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE I r Signature of Permittee Date je pa WOR ~ DMPENSATION DECLARATION MAW DIV 3/87 APPLIC TION FOR ELECTRICAL PERMIT I hereby affil have a certificate of consent to self CE-806G ti O insure, or a cert.,.- ;. of Workers'Compensation Insurance, COUNTY OF t..o ANGELES DEPT. OF PUBLIC WORKS E`•-'• ora,Wrtif,ied copy,thereof(Sec. 3800, Lab. C.) -I Polis No. _Mcb Company—5 1 I�.JIV�`! - FOR APPLICANT TO FILL IN JOB Certified copy is 1hereby furnished. New Residential,Bldgs. &Pools EACH NO. FEE :ADDRESS ICS -I p EMC Certified copy is filed with the county ins ea 1 &2-Family, Sq. Ft. $ — $ LOCALITY L+ t ; tion department. Multi=famil Sq. Ft. y NEAREST r 7-��O Residential Swimming Pools OWNER CROSS OR Date - Applicant FIRM NAMECHAMP/or— r>cv1 CERTIFICATE OF EXEMPTION FROM WORKERS' Out I L, ec Li ht $w. o MAIL COMPENSATION INSURANCE g �� 8 ADDRESS first.20 (This section need not be completed if the work involved by CITY r Tel. No. /� the permit is for one hundred dollars($100)or less.) Total No. dditional G &,C, E)E�Cry �. 'y0f lc PLAN CHECK � I certify that in the performance of-the work for which this APPLICANT ® �-1-'f4 A-1 ' permit is issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws. Li ting Fixtures First 20 ADDRESS ( �I'1r] Date Applicant' To� Additional CITYftfl Tel. N a _ o.� -l-- N� �� o. - a .J NOTICE TO APPLICANT: If, after making this Certificate of. Fixed Appliances.Not ver 1 FIP ,PERMIT Exemption, you should become subject to the Workers' Range--,-) Heater—D.W. — APPLICATION Compensation provisions of the Labor Code,.you.must forth- Oven — Dryer —W.M.— . ADDRESS i �(/�' � with. comply with such provisions or this permit shall be Top — FAU —W.H. — deemed revoked. CITY Tel. No. 630 ,2 . Hood n flier_ - LICENSED CONTRACTORS DECLARATION 'LICENSE OR I / eX7LJ I hereby affirm that I am licensed under provisions of Chapter 9 Disp. Roo and. — REG. NUMBER t7b Class.C`I�' (commencing with Section 7000)of Division 3 of the Business Power Apparatus&Large Appliances DISTRICT NO. P9gESSED BY and Professions Code,and my license is in full force and effect. a `` `O Size&Type HP, KW, KVA, or KVAR 8� :ded-Q_r CGc.J O License Number b(0W I ic. Class r to 1 Incl. FINAL V � � �� , 1� 1 -q3 C' Wer 1 to 10 Incl. .DATE �3.q� VALIDATION cc Contractor, Date41 ( ler 10 to 50 Incl U F1 FINAL I am exempt:under Sec. Over 50 to 100 Ine. BY LU B.&P,C. for this reason fes( Over 100 o- U) Date: Services, Swbd.,.MCC&Pon@Iboards /d�gp3 sZ 0-200 Amp. Under 600 V .�77PIP — Signature - 201 - 1000 Amp. Under 600 V• IDOver,l000J4mp, or Over 600 V Exemption for Reg. Maint. Elect. SINGLE FAMILY ACCT°T mfs"P we Pole&Appurtenances 4;_ �r HOME OWNER-BUILDER DECLARATION ��U}r +��•._°_tit Sign with ne Branch'Circuit I hereby affirm that.I am exempt from the Contractor's License r—^ Law for the following reason (Section 7031.5, Business and al Sign Branch Circuits y [ ^j°f Professions Code): `' _ ��.�® �� Misc. Conduits&Conductors Teff KLIJi, as owner of the property, will do the work and the , W.].°+`+}� structure is not intended or offered for sale(Section 7044', Other(See'Complete Fee Schedule)_ CHECK Business and Professions Code). r CHN4t- °!,!'-. 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 PERMIT FEE Sub-Total (Sec. 3097, Civ. C.). PLAN CHECKING FEE U _3 `s. A11TLJ.`) Lender's Name ' PERMIT ISSUING FEE Lender's Address TOTAL FEE I certify that I have read this application and state that the above information is correct. I agree to comply with all County `� ordinances and State laws regulating Electrical wiring, and �v)L�l� A II hereb .1h representati f this County to enter upon ��! �+' th e-mention oper inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date ; ®` WORKF-- -OMPENSATION DECLARATION 76-806 10/81 ' A�it?L ON FOR ELECTRICAL PERMIT hereby affirm thi re a certificate of consent to self Insure,' CE-806G �" IC or a certificate of .'S' Compensation Insurance,or a certified COUNTY OF LUo HNGELES BUILDING AND SAFETY U copy thereof(Sec.3800,Lab.C.) _ n Policy No. Company Z-5 r4 6 cJle�.� FOR APPLICANT TO FILL IN. .JOB �Certified copy is hereby furnished. New.Residential Bldgs.&Pools EACH NO. FEE .ADDRESS - ❑ 1 &2-Family,Sq.Ft. $ — $ LOCALITY Certified copy is filed with the county building inspection de artenNEAREST t. Multi-family Sq.Ft. CROSS ST. Date 4011y_ i/ Applicant Residential Swimming.Poois OWNER OR ,/ , FIRM NAME .Q�l/- CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:.Rec "' Light Ql_ SW..'� SIL 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.) Tel.No. �� I certify that•in.the performAPPLICANT of the Work.for which this permit PLAN CHECK is issued, I;shall. not employ any person in any manner so as to ADDRESS become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 �q Additional Total No..�L -CITY Tel.No. Date. Applicant Fixed Appliances Not Over 1 HP PERMIT NOTICE TO APPLICANT: If, after making this Certificate. of APPLICANT Exemption,you ahould.become subject to the Workers'Compensation Range_ Heater_ D.W. _ provIbions of the Labor lode,you:must forthwith comply with such Oven Dryer_ W.M._ ADDRESS a p• j e, provisions or this permit shall be.deemed revoked. Top .— FAU W.H. _ CITYNo'li3o- LICENSED CONTRACTORS DECLARATION Hood — Fan Other_ I hereby,affirm that.I am licensed under provisions of Chapter g R (commencing with Section 7000)of Division 3 of the Business and Disp. — 'Room Air Cond: _ REEG.G.NUMBER ER ��`, Cis.�i/Q Professions Code,and my license is in full force and effect. Paver Apparatus&Large Appliances DISTRICT NO. PRO ED BYi _ Sizg& pe HP,.KW,KVA,or KVAR U(� Q License Numbers Lic.Class lJp to 1 Incl. 0 FINAL v / Over 1 to 10 Incl. pp DATE `,3 . VALIDATION C CohtractoL /�Li.Date�-3�� ?/ .JF Over 1.0 to 50 Incl. El FINAL I am exempt under Sec. Over 5.0 to 100 Inc. BY Lal B:&P,C:for this reason Over 100 Services,Swbd:,MCC&Panelboards' Q Z ' Date: 0-20O Amp.Under 600 V Q •.:'7i Signature 201 - 1000 Amp.Under 600 V w�( -`'=°+�C Over 1000 Amp.or Over 600 V 4 T ❑ Exemption for Reg.Maint.Elect. HENS:.'TO _ SINGLE FAMILY Temp.Power Pole&Appurtenances T � m " ` -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 following reason(Section 7031.5,Business and Professions Code) L1HtiU_ °L+t: ❑ i,as owner of the property,will do the work and the structure Misc.Conddits&Conductors Fee Schedule) is not intended or offered for sale (Section 7044, Business Other(See Complete � � .�:�'?i s and Professions Code). , t CONSTRUCTIONIENDING AGENCY 5-6 t)3 )` G�`�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 �3 , Lender's Address I certify that I have read this application and state that the above TOTAL FEE d 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 ' proper r inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Igha ure of i Date 6 WORKERS'COMPENSATION DECLARATION 20-0019 DPW 3/87 APPLICATION FOR ELECTRICAL PERMIT Q I hereby affirm that 1 have a certificate of consent to self ce-e�a insure, or a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS or a certified copy thereof (Sec. 3800, Lab. C.) Policy No. Company FOR APPLICANT TO FILL IN JOB �7 ltD Certified copy is hereby furnished. New Residential Bldgs. &Pools EACH NO. FEE ADDRESS 51-21 — 574KoswmAO Big _ Certified copy is filed with the county building inspec- 1 &2-Family, Sq. Ft. $ $ LOCALITY Tg M we C,I TNEAREST tion department. Multi-family Sq. Ft. CROSS ST. LAS TLI o k i Date Applicant DP- Residential Swimming Pools OWNER OR 1 FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' i Outlets: Rec Li ht Sw.— MAIL "`•- COMPENSATION INSURANCE g ADDRESS 100 OC.0Afl� First 20 (This section need not be completed if the work involved by Total No. Additional CITY Lt) , Be-/cp G +n' ' x137 the permit Is for one hundred dollars(;100)or less.) PLAN CHECK L. a-s�^� 1 7'=e; j: I certify that in the performance of the work for which this APPLICANT DAa ��'�°+ L= permit is issued, I shall not employ any person in any mannert J so as to become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS 8638 AAR.1; Agt;i`i•_ Additional Total No. CITY 0OR-T11 L,, Gla 1-fwNo' 't fi0 Date Applicant Fixed Appliances Not Over 1 HP PP PERMIT "-� •";.•" NOTICE TO APPLICANT: If, after making this Certificate of APPLICATION '-HECK 1_0 Exemption, you should become subject to the Workers' Range— Heater—D.W. — _ Compensation provisions of the Labor Code, you must forth- Oven — Dryer —W.M.— ADDRESS CHANGE !�= with comply with such provisions or this permit shall be Top — FAU —W.H. — deemed revoked. Hood — Fan —Other— CITY Tel. No. LICENSED CONTRACTORS DECLARATION Disp. — Room Air Cond. — LICENSE OR I}" "1 __"ice'+ I hereby affirm that I am licensed under provisions of Chapter 9 REG. NUMBER l,,1'l,;l ' I s• (commencing with Section 7000)of Division 3 of the Business Power Apparatus&Large Appliances DISTRICT NO. SSED BY; I I 1} and Professions Code,and my license is in full force and effect. �� a Size&Type HP, KW, KVA, or KVAR O License Number. Lic. Class Up to 1 Incl. FINAL U Contractor Date Over 1 to 10 Incl. 1 OC7 DATE VALIDATION 0 i5 TR&JILE Over 10 to 50 Incl. 3 O 230 `s O ❑ FINAL — U I am exempt under Sec. Over 50 to 100 Inc, BY i=;1rC'l ,F LU Over 100 jLi. t B.BP.C. for this reason vL:ll� j Services, Swbd., MCC&Ponelboards Z Date: 0-200 Amp. Under 600 V ® O 00 ® 1 T i EMS — Signature 201 - 1000 Amp. Under 600 V 3 r(- iL e r(_ ❑ Over 1000 Amp. or Over 600 V �,, �7, �- Exemption for Reg. Maint. Elect. :,I ECK ��o 10, SINGLE FAMILY Tem Power Pole&A HOME OWNER-BUILDER DECLARATION p' Appurtenances CHANGE ��'() I hereby affirm that I am exempt from the Contractor's License Sign with One Branch Circuit Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits Professions Code): [000-0011'] Misc. Conduits&Conductors Tv'O .. o- I, as owner of the property, will do the work and the ® 22.1 1 Fri 5:0IL structure is not intended or offered for sale(Section 7044, Other JSee Complete Fee Schedule)— 0 Business and Professions Code). t� p CONSTRUCTION LENDING AGENCY 2 VO C i is T 30 TS 00 UU'� 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued PERMIT FEE (Sub-Total)—* rJZ�'✓'�''Ca � (Sec. 3097, Civ. C.). �r PLAN CHECKING FEE 1,Z?j� D iiJV'o� Lender's Name PERMIT ISSUING FEE Lender's Address I certify that I have read this application and state that the ITOTAL FEE above 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 inspection purposes. VVV SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date ®°