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Home My Public Portal About5751-5757 ROSEMEAD BLVD_Electrical__ WORKE`""^'1MPENSATION DECLARATION. CE-806G 10161 Li PP��CI �� ®R ELECTRICAL PERMIT I hereby affirm that b:a certificate of consent to self insure, i�! or a. certificate of t.._.._.a'-Compensation Insurance,or a:certified COUNTY OF LC._ _AGELES BUILDING AND SAFETY'' copy thereof(Sec.3800,Lab.C.) POIIC / `3 i ocompany - M— J�� FOR APPLICANT TO FILL IN JOB E Certified copy is hereby furnished. t New Residential Bldgs.&Pools NO. ADDRESS EACH FEE 1 &2-Family, Ft. $' — $ LOCALITY ❑ Certified copy is filed`with the.county' building. inspection y'�' _ NEAREST • d rtment. ' ,: Multi-family Sq.Ft. GROSS ST. Date 'O/Applicant Residential Swimming Pools OWNER.OR - FIRM NAME CERTIFICATE..:OF EXEMPTION'FROM WORKERS' MAIL Outlets:Rec—Light Sw.— COMPENSATION INSURANCE ADDRESS ,0d e . (This section need not be completed N the work involved by the First 20 CITY Tei.No. permit is for.one hundred dollars($1'00)or less.) Total No.. Additional• bp GCi I certify,that in the performance of,the work for which this:permit PLAN CHECKAPPLICANT iff4ssued, I shall not employ any person in any manner so as to become,subjectto the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS Total No. Additional CITY Tel.No. Date Applicant � Fixed Appliances Not Over 1 HP NOTICE 'TO. APPLICANT: If; after making this Certificate of' �s PERMIT Exemption,;you should become subject to the Workers'Compensation Range_ Heated D.W. APPLICANT provisions of the Labor Code,you must'forthwith comply with such Oven Dryer_ W.M._ ADDRESS 0 provisions or thls.permit shall be deemed revoked. Top FAU •_ W.W.- 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. Class��(� REG,NUMBE Professions Code,and•niy,lidense is.in full force and effect. Power Apparatus&-Large Appliances Distm r No. 'PROCE ED BY Size&Type HP,KW,KVA,or)(VAR �� 'Q� License Numbs Lic.Class el—le � �✓Up to 1 Incl. 0 FINAL •p /y Over 1 to 10 Incl. DATE C�1 Contractor 31-!`7 VALIDATION 0 Over 10.to 50 incl. FINAL ••. ❑ f am exempt under Sec. Over 50 to 1.00 Inc..- By W BAP,.C.for this reason _ ti• Over 1.00' IL' Services,Swbd.,MCC&Panelboards. ® Z Date: 0-200 Amp.Under 600 V Signature 201 -1000 Amp.Under 600 V ❑ Over 1000 Amp.or Over 800 V "k Exemption for Reg.Maint.Elect. r SINGLE FAMILY Temp.Power Pole 4 Appurtenances Ai.C r a a HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit '+,:_ (7 �� e��; I'hereby affirm that I am exempt from the Contractor's License Law Additional.Si n Branch Circuits ' for the following reason(Section 7031,5,Business and Professions g I "Eli Code): Misc.Conduits&Conductors TOTAL 31__60 ❑ I,as owner of the property,will do the work and the'structure Other(See Complete Fee Schedule),_ CHECK a is not Intended or offered for sale (Section 7044, Business and Professions Code.). • CONSTRUCTION LENDING AGENCY HANGS , ,lye 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.) i Civ.C.). PLAN CHECKING FEE i' Ll {; t�a;z Lender's Name S n i •'_a Leti 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 mo; / and State laws regulating Itleetr'ical wiring, and hereby authorize representatives of this County to enter upon the above-mentioned ,0 (f,� P per r Inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE • Signature of WrmM / Date t _ .0 1 WORK' � OMPENSATION DECLARATION '2019 DPW 3/87 !`�~ . 76A663 hereby affirm I have a certificate of consent to self. APPLIC ION FOR ELECTRICAL PERMIT � � O insure, or edcert co of Workers'Compensation Insurance, COUNTY OF .�.� ANGELES DEPT. OF PUBLIC WORKS or a certified copy thereof (Sec. 3800,Lob. • y Poli No�Company GSL' Lt� FOR APPLICANT TO FILL.IN JOB �y ADDRESS s 5I -5/ l� Certified copy is hereby furnished. �-`/--��- New Residential Bldgs. &Pools EACH —N-0.1—FEE. _ ❑Certified copy is filed with the county buildin inspec- 1 &2-Family, Sq. Ft- ,. $: — $ LOCALITY tion department. Multi-family Sq. Ft.. — NEAREST 1 Residential Swimming Pools', I CROSS ST. S Date XApplican t OWNER OR . FIRM NAME C lP/Oti _v CERTIFICATE OF EXEMPTION FROM WORKERS' ! Outlets: Rec ght Sw.� MAIL / L1' ADDRESS � IJL Eft- _ G COMPENSATION INSURANCE �� (This section need not be completed if the work Involved by Total No._ First ti % d CITY 22 Tel. No. �f pL,�j the permit is for one hundred dollars:($100)or less.).!, Additional / a� O 0"T PLAN CHECK I certify that in the performance of the work for wh'ieh this APPLICANT 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 % �a ADDRESS Additional % O I Total No. �� CITY �1D T.I. No. ■aJ Date Applicant Fixed Appliances Not Over 1 HP PERMIT NOTICE TO APPLICANT: If, after making this Certificate .of �GAPPLICATION .meq e— Heater—D.W. C(_ C. 1 IL' Exemption, you should become subject to the Workers' Ran 9 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 Hood. — Fan —Other— Tel. No. LICENSED CONTRACTORS DECLARATION, f LICENSE OR Disp. .— Robm-ArCond. — �� Class,C10 I hereby affirm that I am licensed under provisions REG of Chapter 9 ..NUMBER (commencing with.Section 7000)of-Division 3 of the Business 'Power Apparatus.&Large Appliances DISTRICT NO. PROCESSED BY d and Professions'Code;and-my license is in full force and effect. - y � ,a C Size&Type HP, KW; KVA, or KVAR L7• �L aG-L U License Number �J Lie. Class _V0 Up to 1 Incl. FINAL C% Over 1 to 10 Incl. •B1U 00 DATE _ VALIDATION � Contractor Date 7- � Over 10 to 50 Incl. �: FINAL 11-- I am exempt under Sec. Over 50 to 100 Inc. BY W B.&P.C.for this reason Over 100 co0. Services, Swbd., MCC&Panelboards , Z Date: -G-200 Amp. Under 600 V Signature 201 - 1000 Amp. Under 600 V ' ❑ :Exemption for Reg.Maint. Elect.. Over 1000 Amp: or Over 600 V r SINGLE FAMILY Tem Power Pole&Appurtenances y HOME OWNER=BUILDER DECLARATION p' pp ACU■a I hereby offirm'that I am exempt from.the Contractor's License. Sign with One Branch Circuit Law for the following Peason (Section 7031,5, Business and Additional Sign Branch Circuits ";(]7 L 6&GlJ Professions Code): g{ Misc. Conduits&Conductors❑ I, as owner of the property, will do the work and the r.-� 366. 60 , r ,. structure is not intended or offered for sale(Section'7044, Other(See Complete Fee Schedule)— t OTAL 366 m 60 Business and Professions Code). , 4�re-VECK 366.6-.1, CONSTRUCTION LENDING AGENCY I hereby affirm that there is a-construction lending agency for �� ■l�l the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) �f Q (Sec. 3097, Civ. C.Y. � r� PLAN CHECKING-FEE s.000-01Ll.f ? �Yf 3- Lender's Name PERMIT ISSUING FEE �,3 8114 1 An11:17 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 laws regulating Electrical wiring,-and V I`0'�L-- C he uthoriie representatives of this County to enter upon e pr rt or inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE " (4T ®s Signature o, ermittee Date i I WORKERS'COMPENSATION DECLARATION 72D-0019&A" 3/87 APPLICATION FOR ELECTRICAL PERMIT I hereby affirm that I have a certificate of consent to self CE-twee insure, or a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELESI DEPT. OF PUBLIC WORKS or a certified copy thereof(Sec. 3800, Lob. C.) Policy No. Company FOR APPLICANT TO FILL IN JOB p ❑Certified copy is hereby furnished. New Residential Bldgs. &Pools EACH NO. FEE ADDRESS �1 S 51 Sol KWLr1qXAb RLd ❑Certified copy is filed with the county building inspec- 1 1 &2-Family,Sq. Ft. $ — $ TTL LocALITY L.� C tion department. Multi-family Sq. Ft. — NEAREST U dA.f CROSS ST. L " Residential Swimming Pools OWNER OR t� Date Applicant FIRM NAME C14410r 10 bisV CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw._ ADDRESS i00 OCLfla11 C9 1.� 'r rdOO IL First COMPENSATION INSURANCE (This section need not be completed if the work involved by Total No. Addi?onal CITY L -O&)G a(ac I a,:�I. No.437 -9o44 the permit is for one hundred dollars($100)or less.) PLAN CHECK +'r'' z I certify that in the performance of the work for which this APPLICANT D�Lbi�1 l:ts' °z permit is issued, I shall not employ any person in any manner Lighting Fixtures First 20 ADDRESS so as to become subject to the Workers'Compensation Laws. I g g gC 3IS fl Additional i Date Applicant Total No. 41TY 0aI ..e Tel. Pilo.-� .za O Fixed Appliances Not Over 1 HP PERMIT f� �L:1 NOTICE TO APPLICANT: If, after making this Certificate of 11 r�L. '=3 = APPLICATION 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 CHECK 4.i ),I.i with comply with such provisions or this permit shall be Top — FAU —W.H. — CITY '. 15 deemed revoked. Hood — Fan —Other_ LICENSED CONTRACTORS DECLARATION LICENSE OR Disp. _ Room Air Cond. Class. I hereby affirm that I am licensed under provisions of Chapter 9 REG. NUMBER (commencing with Section 7000)of Division 3 of the Business Power Apparatus&Large Appliances DISTRICT NO. JBL( l:s77 ?a and Professions Code,and my license is in full force and effect. p 4 , Size&Type HP, KW, KVA, or KVAR ,�a ` PMI '_.o License Number Lic. Class Up to 1 Incl. FINAL U 5 Over 1 to 10 Incl. n DATE H`;{; LIDATION Q Contractor DateS 7RA.1L31 Over 10 to 50 Incl. 005 ADD—DD !-. INAL ._wls? 1L�.,■:ttDi ❑ I am exempt under Sec. Over 50 to 100 Inc. Y [a B.&P.C. for this reason Over 100 1 ITEMS D.. Date: Services, Swbd., MCC&Panelboards 1&00 if ® I I FAIL o �U) 0-200 Amp. Under 600 V Signature 201 - 1000 Amp. Under 600 V CHECK 331° Il' ❑ Exemption for Reg. Maint. Elect. Over 1000 Amp. or Over 600 V CHAINGE i °t�L SINGLE FAMILY i Temp. Power Pole&Appurtenances HOME OWNER-BUILDER DECLARATION 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 1 Additional Sign Branch Circuits .,: Professions Code): l ❑ I, as owner of the property, will do the work and the Misc. Conduits&Conductors ) structure is not intended or offered for sale(Section 7044, Other( e a Complete Fee Schedule)- -T cheddule)_ �J Business and Professions Code). ` CONSTRUCTION LENDING AGENCY 2111 VrjL.T CiftC_UiTr 12.60 i0 1 1L,5 go 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) alp%D a (Sec. 3097, Civ. C.). Pp PLAN CHECKING FEE '?jU 6U 7E%7' y Lender's Name If PERMIT ISSUING FEE Lender's Address �YY I certify that I have read this application and statethat the TOTAL FEE ` ti above information is correct. I agree to comply with all County `% 1� ordinances and State laws regulating Electrical wiring, and BIJ I L.b 1#3 (r C hereby authorize representatives of this County to enter upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date WORKERS'COMPENSATION DECLARATION 40-0019 DPW 3/87 ��[�� ELECTRICAL ��n/fii� • II 663 I h affirm that I have a certificate of consent to self c� N r`Ad L� 9 A saw ILJI 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.) �1 C' ,�� JOB Policy No. Company FOR APPLICANT TO FILL IN FEE ADDRESS5 !SI -5-169 7°J 9 ?.o L MLfAb R1.0❑Certified copy is hereby furnished. New Residential Bldgs. &Pools - EACH NO. ❑Certified copy is filed with the county building inspec- 1 &2-Family, Sq. Ft. $ _ $ LOCALITY 'fG L lr C tion department.' Multi-family Sq. Ft. NEAREST CROSS ST. Lk r -rV Date Applicant Residential Swimming Pools CWNER OR F-RM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw._ 'SIL # r.aC4 COMPENSATION INSURANCE ADDRESS 100 OCi:laa Ga`rL This section need not be completed if the work involved b First ti CITY LOA�C- %dAc-�.+ CA,t el. No. Lt37 '^804& the permit is for one hundred dollars ($100)or less.) y Total No. Additional r�.r K , PLAN CHECK I certify that in the performance of the work for which this APPLICANT DILL-b:.15 '6 1.1r permit is issued,I shall not employ any person in any manner -1 so as to become subject to the Workers'Compensation Laws. Additional 3 Total No. CITY ,15C jr /Tel. PJor �".�2� Date Applicant Fixed Appliances Not Over 1 HP PERMIT I i j AL 4:5 a1 J0 NOTICE TO APPLICANT: If, after making this Certi:icate of APPLICATION _ Exemption, you should become subject to the Workers' Range— Heater—D.W. — CHECK h t Compensation provisions of the Labor Code, you must forth- Oven — Dryer —W.M.— ADDRESS = 's-�-''` with comply with such provisions or this permit shall be Top — FAU —W.H. — ,lll.I CITY deemed revoked. Hood — Fan —Other— ICE OR LICENSED CONTRACTORS DECLARATION Disp. — Room Air Cond. — _ I hereby affirm that I am licensed under provisions of Chapter 9 zEG.G. NUMBER BER Class. (commencing with Section 7000)of Division 3 of the Business Power Apparatus&Large Appliances DISTRICT NO. and Professions Code,and my license is in full force and effect. '4 Size&Type HP, KW, KVA, or KVAR License Number Lic. Class— Up to 1 Incl. FINAL `= s Over 1 to l0 Incl. �. DATE ` Vi: V%LIDATION 00 Contractor Date 5'9 S DU S ____ __ J- _ � Over 10 to 50 Incl. FINAL I am exempt under Sec. Over 50 to 100 Inc. BY 4s�:; i _M, CLl Over 100 1 1 11 a_i'E�r d B.&P.C. for this reason ull Services, Swbd., MCC 8 Panelboards -'AQ B m 59 Date: 0-200 Amp. Under 600 V E iii._ 7-V _ Signature 201 - 1000 Amp. Under 600 V CREEK Exemption for Reg. Maint. Elect. Over 1000 Amp. or Over 600 V SINGLE FAMILY Temp. Power Pole&Appurtenances HOME OWNER-BUILDER DECLARATION G !C.' ' I hereby affirm that I am exempt from the Contractor's License Sign with One Branch Circuit 0101,00-000 Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits Professions Code): IDI, as owner of the property, will do the work and the Misc. Conduits&Conductors structure is not intended or offered for sale(Section 7044, O`hOer (SeeLCOmp�te Fee Schedule _ _ �l✓ Business and Professions Code). �4 CONSTRUCTION LENDING AGENCY 27.1 oL• G R GLl r C1 !c7 125 CLI 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) 76, ;. (Sec. 3097, Civ. C.). PLAN CHECKING FEE ?j�j� >:j(} Lender's Name PERMIT ISSUING FEE Lender's Address I 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 laws regulating Electrical wiring, and BLi I L.D hereby authorize representatives Of this County to enter upon the above-mentioned property for inspection purpoces. SEE REVERSE FOR EXPLANATORY LANGUAGE