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Home My Public Portal About5805 ROSEMEAD BLVD_Electrical__ Y_ % 23 A40 {J !WORKER'S COMPENSATION DECLARATION 20.0019 DPW(12-91) APPLICATION FOR ELECTRICAL PERMIT lJ I hereby affirm that I have a certificate of consent to self insure, 78A663 87 a certificate of Worker's 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,��9' Company /! ?� �^ � FOR APPLICANT TO FlLL IN ADDRESS Ave- Certified copy Is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE $ $ LOCALITY ❑ Certified copy is filed with the.county building inspection 1 &2-Family,Sq.Ft. _ NEAREST department. Multi-family Sq.Ft. CROSS ST. Date 4'Z� Applicant 2�� ka?Al Residential Swimming Pools ASSESSOR 1 MAP BOOK PAGE PARCEL. CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec. Light_/K Sw. OWNER OR COMPENSATION INSURANCE v' ®� �y FIRM NAME his section need not be completed if the work Involved b the First io [/ MAIL CT P Y Total No. Additional p'j D D-ADDRESS permit la for one hundred dollars($100)or less.) 'I certify that in the performance of the work for which this permit CITY Tel.No. Is issued, I shall not employ any person in any manner so as to PLAN CHECK become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 . APPLICANT Total No. Additional ADDRESS Date Applicant RESIDENTIAL APPLIANCES OVER 3 HP. NOTICE TO APPLICANT: If, after making this Certificate of �g,, CITY Tel.No. Exemption,you should become subject to the Workers'Compensation OTHER APPLIANCES N R 3 HP. rovlsions of the Labor Code,you must forthwith comply with such APPLICANT T l p Y P Y APPLICANT c/ provisions or this permit shall be deemed revoked. Power Apparatus&Large Appliances LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS 1 hereby affirm that I am licensed under provisions of Chapter 9 �_ Over 3 to 10 Incl. CITY Tel.N (commencing with Section 7000) of Division 3 of the'Business and Professions Code,and m license is in full force and effect. Over 10 to 50 Incl. } Y LESGNSEOR 0 Class. Over 50 to 100 Incl. REG:'NUMBER ♦1 Over 100 DISTRICT NO. '' PR ED BY 0 License Number e?-7�/7 Lic.Class l3 `� Services',Swbd.,MCC&Panelboards Contractor_��T�E7r� ate 4~a Ar—'re 0-399 Amp.Under 600 V• FNA 0 VALIDATION 400-1000 Amp.Under 600.V V ❑ I am exempt under Sec. Over 1000 Amp.or Over 600 V FINAL LI B,&P.C.for this reason. BRANCH CIRCUIT FEES BY CL IA Date: 15A,or 20A,120V,-Lighting or Recept. Z_ 1 To 10 Brandh-Circuits. Signature 11 To 40 Branch Circuits �Q� ❑ p g 41 Lighting Circuits `�^'^'l"'ITF�'� 149.50 Exemption for Reg.Maint.Elect. 15A,20A,208V To 277V'Li htin Br:Circuits �. SINGLE FAMILY Temp.Power Pole&Appurtenances TOTAL ]!. 09-50 HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit I hereby affirm-that I am exempt from the Contractor's License Law for thefollowing reason(Section 7031.5, Business and Professions Additional Sign Branch Circuits E 1490gn Code): ❑ I,as owner of the property,will do the work and the structure Misc.Conduits&Conductors Is not Intended or offered for sale(Section.7044, Business Other(See Complete Fee Schedule) and Professions Code). , [� -QQ01 5/ 9/96 CONSTRUCTION LENDING AGENCY 635241 AM10'-55 1 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 W Lender's Name PERMIT ISSUING FEE Lender's Address penalty of ur'u J ry state TOTAL FEE A57 I certify that I have read this application and under p that the above information is correct. I agree to comply with p all County ordinances and State laws regulating Electrical wiring,and hereby authorize representatives of this Count to enter upon the above-mentioned property for 1 tion pur a SEE REVERSE FOR EXPLANATORY LANGUAGE 711 SIG OF P RM E RDATE � WORKER'S COMPENSATION DECLARATION 20.0019 DPW(12-91) I I 7SA663 APPLICATION FOR ELECTRICAL PERMIT LI II hereby affirm that I have a certificate of consent to self Insure, for a certificate of Worker's.Compensation Insurance, or a certified COUNTY OF LOS.ANGELES DEPT..OF PUBLIC WORKS BUILDING AND SAFETY DIV. copy thereof(Sec.3800 Lab.C.) j — Q® � FOR APPLICANT TO FILL IN JOB policy❑ y NO. EACH FEE ADDRESS.S �. Certified copy.is hereby furnished. ��— New Residential Bldgs.&Pools _ $ $ LOCALITY ri Certified copy is filed with the county build' I tion 1 &2-Family,Sq.Ft. _ NEAREST department. / Multi4amily Sq.Ft. CROSS ST. Date —�+ "`" Applicant esidential Swimming Pools ASSESSOR MAP BOOK PAGE. PARCEL CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec._Light 2a Sw. OWNER OR COMPENSATION INSURANCE First 20 e-� FIRM NAME pThis section need not be completed if the work Involved by the MAIL ermit Is for one hundred dollars(S10.0)or less.) Total No. Additional ADDRESS Q� I certify that in the performance of the work for which this permit CI Tel.No. i is Issued, I shall.not employ any person in any manner so as to PLAN CHECK become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 APPLICANT Total No. Additional ADDRESS Date Applicant RESIDENTIAL APPLIANCES NOT OVER 3 HP. NOTICE TO APPLICANT: If, after making this Certificate of CITY Tel.No. Exemption,you should become subject to the Workers'Compensation OTHER APPLIANCES NOT OVER 3 HP; rovisions of the Labor Code,you must forthwith comply with such PERMIT _ p p Y P Y APPLICANT. provisions-or this permit shall be deemed revoked. Power Apparatus&Large Appliances - LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS I hereby affirm that I am licensed under provisions of Chapter 9 Over 3 to 10 Incl. (commencing with Section 7000)•of Division 3 of the Business and CITY A") Tel.Nom` . Professions Code,and my license is in full force and effect. Over 10 to 50 Incl.. Over 50 to 100 Incl. HIS NUMBER j t Class: a Over 100 DISTRICT'NO. P OCESSED BY O License Number `- LIL Class U ��."}�, Services,Swbd.,MCC'&Panelboards Contractor'—� '� 'i, ' �a� ate b0-389 Amp.Under 600 V DATE ❑ 400-1000 Amp.Under 600 VV I am exempt under Sec. Z_ VALIDATION d Over 1000 Amp.or Over 600 V FINAL B..&P.C.for this reason BRANCH CIRCUIT FEES BY Date: 15A,or 20A,120V,Lighting or Recept. _ 1 To 10 Branch Circuits Signature 11 To 40 Branch Circuits 41 Or More Branch Circuits ❑ Exemption for Reg.Maint.Elect. 15A,20A,208V To 277V Lighting Br.Circuits SINGLE FAMILY Temp.Power Pole&Appurtenances 2 HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit AGGTJL I hereby affirm that I am exempt from the Contractor's License Law e for the following reason(Section 7031.5, Business and Professions Additional Sign Branch Circuits Code): 330$ 71■95 ❑ I,as owner of the property,will do the work and the structure Misc.Conduits&Conductors 1 ITEMS Is not intended or offered for sale(Section 7044, Business Other(See Complete Fee Schedule) , TOTAL 71.95 and Professions Code). CHECK 71e9 CONSTRUCTION LENDING AGENCY n 1 hereby affirm that there is a,construction lending agency for the CHANGE A performance of the work for whicti this permit is issued(Sec. 3087, PERMIT FEE (Sub-Total) Civ.C.) PLAN CHECKING'FEE 0000-0001 7!•.8!96 •Lender's Name PERMIT ISSUING FEE 7299 1 Fri 4:11 Lender's Address I certify that I have read this application and under penalty of purjury state ITOTAL FEE r that the 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 ins ecUOn_ eses. SEE REVERSE.FOR EXPLANATORY LANGUAGE SI IPA RE'OF PERMI E - DATE (WORKER'S COMPENSATION DECLARATION 2129DPW(12-91) APPLICATION FOR ELECTRICAL PERMIT lJ I her-eby affirm that I have a certificate of consent to self insure, or a certificate of Worker's 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 APPLICANT TO FILL IN JOB ADDRESS lJ Certified copy is.hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE LOCALI ❑ Certified copy is filed with the county.building inspection 1&2-Family,Sq.Ft. _ $ $ NEAREST department. Multi-family Sq.Ft. CROSS ST. Date Applicant Residential Swimming Pools. ASSESSOR O PAGE PARCEL CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec._Light Sw. OWNER OR COMPENSATION INSURANCE FIRM NAM (This section need not be completed If the work Involved by the First 20 MAIL Total No. Additional ADDRESS permit is for one hundred dollars($700)or less.) I certify that in the performance of the work for which this permit CITY Tel.No. is Issued, I shall not employ any person In any manner so as to PLAN CHECK become subject to the Workers'Compensation Laws. Lighting.Fixtures First 20 APPLICANT _ Total No. Additional ADDRESS Date Z' v Applicant f!j w 0_ � RESIDENTIAL APPLIANCES NOT OVER 3 HP. NOTICE TO AP LICANT: If, after making 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 such PERMIT t p p y Power Apparatus&Large Appliances APPLICANT s provisions or this permit shalt be deemed revoked.. Size&Type HP,KW,KVA,or KVAR ADDRESS oZ N c LICENSED CONTRACTORS.DEGLARATION 3' I hereby affirm that I am licensed under provisions of Chapter 9Over 3 to 10 Incl. CITY Tel.No. �-1�1 22 (commencing with Section 700.0)of Division 3 of the Business and b 0 Professions Code,and:my license is in full force and effect. Over 10 to 50 Incl. LICENSE OR Over 50 to 100'Incl. REG.NUMBER. Class. >" 6 1-2—/6� Over 100 DISTRICT NO. O SSED BY O License Number1:x_-6Iv Lic.Class� (�, r� n Services,Swbd.,MCC&PanelboardsC CGS--Y+d-v Q Contractor � �v 1 Data 2 Q 0-399 Amp.Under 600 V DATE O ❑ 400-1000 Amp.Under 600 V V I am exempt under Sec. VALIDATION Over 1000.Amp.or Over 600 V FINAL Z w B.&P.C.for this reason BRANCH CIRCUIT FEES BY // U- �l( fn Date. I5A;or 20A,120V,Lighting or•Recept. Z 1 To 10 Branch.Circuits Signature- 11 To 40 Branch Circuits 41 Or More Branch Circuits ❑ Exemption for Reg.Maint.Elect. 15A,20A,208V To 277V Lighting Br.Circuits 2 SINGLE FAMILY Temp.Power Pole&Appurtenances ACCT e s, HOMEOWNER-BUILDER DECLARATION Sign with One Branch Circuit +dQ � e� I hereby affirm that I am exempt from the Contractor's License Law for the following reason(Section 7031.5; Business and Professions Additional Sign Branch Circuits Code): ITEMS ❑ Misc.conduits&Conductors TOTAL 66 m 05 I,as owner of the property,will do the work and the structure , is not intended or offered for sale(Section 7044, Business Other;(See Complete Fee Schedule) , CHECK 66.05 and Professions Code). CHANGE "�Q CONSTRUCTION LENDING AGENCY I hereby affirm.that there is a construction lending agency for the Civ.C.) of the work for which this permit is issued (Sec'. 3097, PERMIT FEE (Sub-Total) �� 0000_0001 7/12/96 96 PLAN CHECKING FEE 7409 1 AM 9 e 206 Lender's Name PERMIT ISSUING FEE p� Lender's Address 1 I certify that I have read this application and under penalty of,purjury state TOTAL FEE that the above'Information is correct. I agree to comply with all County I ordinances and State laws regulating Electfical wiring,and hereby authorize representatives of this County to enter upon the above-mentioned property for inspection purposes. / SEE REVERSE:FOR EXPLANATORY LANGUAGE i SIGNATURE OF PER E - DATE ,