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HomeMy Public PortalAbout5771-5801 ROSEMEAD BLVD_Electrical__ WORKEf- - IMPENSATION DECLARATION CEE--8oeG 1 0/81 APPLICA ON FOR ELECTRICAL PERMIT JJ''�� I hereby affirm that i a certificate of consent to self insure, `7 I or a certificate of 4..,.,...,J' Compensation Insurance,.or a certified COUNTY OF LG,; mAGELES BUILDING,AND SAFETY ILJf copy thereof(Sea 3800,Lab.C.) , 'j POMC o.a��✓Corm parry- / � FOR APPLICANT TO FILL IN JOB New Residential Bldgs.&Pools r Certified copy is hereby furnished. EACH NO. FEE ADDRESS �j Certified copy is filed with the county buil Ing inspection 1 &2rFamily,Sq.Ft. $ — $ LOCALITY department. Multi fiamily Sq.Ft. — NEAREST Residential Swimming Pools CROSS ST. Date Applicant OWNER OR �. FIRM NAME CERTIFICATE OF EXEMPTION'FROM WORKERS' MAIL COMPENSATION INSURANCE Outlets Red—Light Sw.— � ADDRESS dike ZD (This section need not be completed If the work Involved by the. First 20 TotaAdditional No. permit is for one hundred dollars($100)or less.) l No. ,� CITY T : _ O I certify that in the performance of the work for•which this permit PLAN C ECK is issued, I shall'not.employ any..person in,any manner.'so as to APPLICANT. ' 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 NOTICE TO APPLICANT: It, after making this Certificate of PERMIT - Exemption,you should become subject to the Workers'Compensat(on Range_. Heater, +D.W. APPLICANT provisions,of the Labor Code.,you.must forthwith comply with.such Oven —. Dryer_ W.M._ ADDRESS 62 provisions or this permit shall be deemed revoked. Top — FAU _ W.H. _ + • CITY` Tel.N' LICENSED CONTRACTORS DECLARATION Hood—. Fan Other_ 3�— I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Alr Cond. LICENSE OR 3�� /O (commencing with Section 7000)of Division 3 of the Business and REG.NUMBER Clea Professions Code,and my license is in full force and effect: Power Apparatus&Large Appliances DISTRICT No. O PR ED BY a / Si &Type'HP,KW,.ON-or KVAR �O 0 License Number 646 9?y Lie..Class 9:� to 1.Incl. D FINAL U `,'J,/r A / `_ 5-d A.4`_ Over 1 to 10 Incl. _ DATE 1 Z VALIDATION O Contractor_ C��'r a.� c/ Dati) Over 10 to 50 Incl. ( U ❑ I am exempt under Sec. Over 50 to 100 Inc. FINALBY LLI BAP.C.for this reason ` Over 100 Services,Swbd.,.MCC&Panelboards ► 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. SINGLE FAMILY Temp.Power Pole&Appurtenances ' 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. 'A�-'�'t'v' for the following reason(Section 7031.5,Business and Professions n- Code):' 53007 Misc.Conduits&Conductors ;;❑ O I,as owner of the property,will do the work and the structure i; 7'�U Other(See Complete.Fee Schedule)not intended or offered for sale (Section 7044, Business and Professions Code). TOTAL 155®20" CONS7UCTION LENDING AGENCY +7 CHECK ECK Ic.5, 22'110 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) CHANGE Civ.C.). PLAWCHECKING FEE Lender's Name PERMIT ISSUING FEE j `-i Lender's Address. ' 9612 1 AN 3: 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 f• r representatives of this County to enter upon the above-mentioned ` Agnature r inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE qYPer Date WORK I have cerci DECLARATION 20-0019 DPW 3/87 APPLK BION FOR ELECTRICAL•'PERMIT � - 'I hereby offirm I have a certificate of consent to self CE-806G O insure, or a cer of Workers'Compensation Insurance, COUNTY OI ANGELES - DEPT. OF PUBLIC WORKS or a.g.-rtified coy thereof(Sec..3800;Laj�'.�';;G ¢ ,, Polic No! � Company 'f Zi > L��Zr^-+ FOR APPLICANT TO FILL IN JOB /"�—t'_C9r�f �S F�L1 ®Certified copy is hereby furnished. /—Y-A New Residential Bldgs. &Pools EACH NO. FEE ADDRESS`S 1 JO" �-f ❑Certified copy is filed with the county building inspec- 1 8 2-Family;Sq. Ft: LOCALITY$ -- $ L T� , tion department. Multi-family-Sq. Ft. NEAREST L^S ^r� 5 y/ q l , . JC Date ~"I +Applicant Residential Swimming CROSS ST Pools OWNER OR ' FIRM NAME EV CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec 11.1 Light Sw2ai ` ' MAIL Q J COMPENSATION INSURANCE 1 O ® ADDRESS OD C'--*— # 6 his section need not be completed if the work involved b First CITY R P Y � Total No.-f=�= Additional � O 6 � LC_Nti+G geAtCk Tel. Nolj .;M6 the permit Is for one hundred dollars(;100)or less.) PLAN CHECK I certify that in the performance.of the work for which this APPLICANT 1�.� . 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 ✓1 ADDRESS WdY l= r. I 15! Additional Date Applicant Total No. ! CITY Q �f1WL Tel. N.o. a�,D. 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—D.W. APPLICATION G L C=LCT. Compensation provisions of the Labor Code, you must forth- Oven — Dryer —W.M:— ADDRESS Q (QJV� 5T- with comply with such provisions or this permit shall be Top FAU —W.H. — deemed revoked. Hood — Fan —Other_ CITY P' =(tom Tel. No.�3Q^�3 LICENSED CONTRACTORS DECLARATION Dis — Room Air Cond..— LICENSEOR / p� I hereby affirm that I am licensed under provisions of.Chapter 9 p• REG. NUMBER bio 1 1 Class. Q (commencing with Section 7000).of Division 3 of the Business Power Apparatus&Large Appliances DISTRICT NO. PR SSED BY and Professions Code,and my license is in full force and effect. p d L�p� C r J Size&Type HP, KW, KVA, or KVAR �LO � U License Nu er / Lic. Class 1 Up to 1 Incl.. FINAL S '- L Over 1 to 10 Incl, 0 DATE .VALIDATION cc Contractor L ( ''Date. �/ Over 10 to 50 Incl. '©Q l� FINAL U ❑ I am exempt under Sec. Over 50 to 100 Inc. BY W B.BP.C. for this reason Over 100 d Z• Services, Swbd.,MCC&Panelboards Z • Date: ' 0-200 Amp. Under 600 V — Signature 201 - 1000 Amp. Under 600 V Over 1000 Amp. or Over 600 V E] Exemptionfor Reg. Maint. Elect. :� , SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Temp. Power Pole&Appurtenances I hereby affirm that I am.exempt from the Contractor Sign with One Branch Circuit s License rt4L�I o$ Law for the following reason (Section MIA A Business and Additional Sign Branch Circuits _ - Professions Code) -611.11� 112''k�6"1 ❑ I, as owner of the property, will do the work and the Misc..Conduits&Conductors � � I iEj y'_: structure is not intended or offered for sale Section 7044, Other(See Complete Fee Schedule- I - .Business and Professions Code). ' CONSTRUCTION.LENDING AGENCY rvt`'IEiti J. to 41a 1 hereby affirm that there is a construction lending agency for CHANGE o D"!the performance of the work foi which this permit is issued PERMIT FEE (Sub-Total) (Sec. 3097, Civ. C.). PLAN CHECKING FEE 4'1 t t r/1010r 1 Lender's Name PERMIT ISSUING FEE �� !� I 15 Lender's Address / u � AMID- 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 I ai�r ordinances and State laws regulating Electrical wiring, and l�U♦L i3(#"-C_ herebhorize r of this County to enter upon f ove-menf ned prope r inspection purposes, SEE REVERSE FOR EXPLANATORY LANGUAGE . . '7-19-g( Signa ofi tee Date ®° WORKERS'COMPENSATION DECLARATION I 20.0019 DPW 3/87 1 hereby affirm that I have a certificate of consent to Self � APPLICATION FOR ELECTRICAL PERMIT Q insure, or a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS or a certified copy thereof(Ser. 3800, Lab. C.) Policy No. Company FOR APPLICANT TO FILL IN JOB ❑Certified copy is hereby furnished. New Residential Bldgs. &Pools EACH NO. FEE ADDRESS 5171 " SCtp 01 Kos l:Ike Rul ❑Certified copy is filed with the county building inspec- 1 &2-Family, Sq. Ft. $ $ :LOCALITY-roL.V C tion department. Multi-family Sq. Ft. NEAREST Residential Swimming Pools .CROSS ST. L.� Date Applicant OWNER OR FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw.— MAIL COMPENSATION INSURANCE ADDRESS E Or-6,t) f: GGO This section need not be com leted if the work Involved b First 20 ( p y Total No. Additional CITY"Ij ��r� T .�,No.W37.$O46 the permit is for one hundred dollars($100)or less.) PLAN CHECK � ��y 1�1'z• 0�� I certify that in (he performance of the work for which this I APPLICANT b �a(r�-'�I■ permit is issued, I shall not employ any person in any manner Lighting Fixtures First 20 ` ADDRESS 7:'f so as to become subject to the Workers'Compensation Laws. I 8 G 3 8 uf�gc� �� -3 1 Additional Date Applicant Total No. CITY got-ToembGe G Tel. No.i' NOTICE TO APPLICANT: If, after making this Certificate of Fixed Appliances Not Over 1 HP PERMIT 'APPLICATION )II `HL ��'�' [XiExemption, 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 1-CK •° r with comply with such provisions or this permit shall be deemed revoked. Top — FAU —W.H. — Hood — Fan —Other— CITY re. b CIL-- LICENSED CONTRACTORS DECLARATION I 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. PR• $E J. =a and Professions Code,and my license is in full force and effect. p 1 P Size&Type HP, KW, KVA, or KVAR � D d�� License Number Lic. Class Up to 1 Incl. FINAL V I6 DATE yv cc Over 1 to 10 Incl. 0 r•-•-VkLIDATION Contractor Date jjC T F 2 00 A jT� ❑ — � Over 10 to 50 Incl. FINAL 1-- I am exempt under Sec. I Over 50 to 100 Inc. BY 330"? S', B.&P.C. for this reason Over 100 ITEMS. Swbd., MCC&Ponelboards Z Date: 0-200 Amp. Under 600 V 2 16 TOTAL 11013.5 Signature 201 - 1000 Am Under 600 V ;• •" g Over 1000 Amp, or Over 600 V •1��CK '1100.0[l ❑ Exemption for Reg. Maint. Elect. (;j-iANGE .01= SINGLE FAMILY Temp. Power Pole&Appurtenances HOME OWNER-BUILDER DECLARATION Sign � I hereby affirm that I am exempt from the Contractor's License I Si g with One Branch Circuit B1-4j91I Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits Professions Code): 32333233PM 5-406 ❑ 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(See Complete Fee Schedule)_ O O Business and Professions Code). Y G e 00 CONSTRUCTION LENDING AGENCY 2 AL- G I itc a mi4 0 0 to_ 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 1,100 00 7414 /,:fj•0 0 Lender's Name PERMIT ISSUING FEE Lender's Address `y f 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 ad i 1-010 G. 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 I WORKERS'COMPENSATION DECLARATION �76A669DPW 3/87 APPLICATION FOR ELECTRICAL PERMIT �' tl hereby affirm that I have a certificate of consent to self :� O insure, or a-certificate of Workers''Compensation Insurance, I COUNTY OF LOS ANGELESI DEPT. OF PUBLIC WORKS or a certified copy thereof(Sec. 3800, Lab. C.) Policy No. Company 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 building inspec- 1 &2-Family, Sq. Ft. $ — $ LOCALITY ❑tion department. Multi-family Sq. Ft. --- NEAREST Residential Swimming Pools CROSS ST. 'Date _ Applicant � OWNER OR FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' ( MAIL COMPENSATION INSURANCE Outlets: Ree Light Sw._ ' ADDRESS. y, First CITY Tel. No. (This section need not be completed if the work involved b the permit is for one hundred dollars(:100)or less.) Total No. Additional �. I certify that in the performance of the.work for which this PLAN CHECK _ � APPLICANT permit is issued, I shall not employ any person in any manner well so as to become subject:to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS 29 01mv Ale Additional Date Applicant Total No. CITY61V Tet- 11 No. 6 NOTICE TO APPLICANT: If, after making this Certificate of Fixed Appliances Not Over 1 HP I 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 with comply With such provisions or this permit shall be Top — FAU —W.H. deemed revoked. 1 CITY Tel. No. Hood — Fan —Other_ i 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. P SSED BY and Professions Code,and my license is in full force and effect. •, _L Size.&Type HP, KW, KVA, or KVAR O License Number - Uc. Class Up to 1 Incl. , FINAL Over 1 to 10 Incl. J DATE VIALIDATION Contractor Date FOver 1.0-to.50 incl. FINAL "�1j 4 s i,�i ❑ I am exempt under Sec. I Over 50 to 100 Inc. FI ��_ W B.&P.C. for this reason Over 100 1 ITEMS• a r .c 7 Date: Services, Swbd., MCC&Panelboards T t-•3, t Il_ -_a d a 0-.200 Amp. Under 600 V p CHECK � {, i Signature 201 = 1000 Amp. Under.60.0 V Over 1000 Amp. or Over 600 V i CHANGE n 013 ❑ Exemption for Reg. Maint. Elect. II � SINGLE FAMILY ITemp. Power Pole&Appurtenances .HOME OWNER-BUILDER DECLARATION I I hereby affirm that I am exempt from the Contractor's License ISign with One Branch Circuit CIlyl r i-,.� _I/�:•_ _i j`-1 �i.iEti'g Law for the following reason (Section 7031.5, Business and (Additional Sign Branch Circuits I y's.. •-6 j-' n'i Professions Code): Conduits&Conductors ❑ I, as owner of the property, will do the work and the iMisc. ,I structure is not intended or offered for sale(Section 7044, Other(S a Complete Fee Schedule)_ � , Business and Professions Code). CONSTRUCTION LENDING AGENCY 1 97xvil, C: Doj I hereby affirm that there is a construction lending agency for r the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) 7 (Sec. 3097, Civ. C.). Lender's Name IPLAN CHECKING FEE PERMIT ISSUING FEE I , Lender's Address I certify that 1 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 PUI 071 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 �� 2-7 73 9?+,D ®°