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Home My Public Portal About5809-5819 ROSEMEAD BLVD_Electrical__ WORI 'SrCOMPENSATION DECLARATION 20 p019'DPW 9'189 $'' ' I hereb;r'aRfrrti t�;at,'I have a certificate of consent to self insure, '�� APPLICATION FOR EL' EC TRICAL PERMIT or a certiftcate of Worker's.Compensation Insurance, or a certified COUNTY OF LOS ANGELES 'DEPT.OF PUBLIC WORKS BUILDING AND SAFETY DIV. 'Copy,thereof(Seca3800Lab.C.), I� P No:10S M__ Company 5 ri \LVN FOR APPLICANT TO-FILL IN JOB ADDRESS d O O Certified copy is hereby furnished. � EACH NO. !TF 7 NevirResidential Bldgs.&PoolsLOCALITY 1&2-Family,.'Sq.Ft. $ R�, .+ $ s .s. Certified copy is filed with the county building inspection _ NEARE.ST departmellL. Multi-family Sq.Ft. CROSS T. Residential Swimming Pools. Date Applicant R'Q,NI 14 Qdbetet 3' ," ASSESSOR . MAP BOOK' PAGE _ IPARGEL- CERTIFICATEOF EXEMPTION FROM WO RKER$' Outlets:Red Light Sw.�a OWNER OR COMPENSATION INSURANCE g FIRM NAME, G First 20 �i 70.. d O (This.section need not.be Completed if the work Involvar ed by,the f�� i ' MAIL -m- permit is..•.for one hundred dollars($100)or less.) Total No. Additional ' :�I certify that in the performance of the work for which this permit CITY Mme-, 61 �V•e,. el'N' 1[� `1.3 is issued, I shall not employ any person in any manner so as toPIAN CHECK become"subjebt to the Workers'Compensation Laws. Lighting Fixtures First 20 a APPLICANT Total No- Additional, '✓ ADDRESS DateApplicant. !vi 'CIRGUIT ryt NOTICE'TO' APPLICANT: 11, aftet 15 OR 20A,120V BRANCH making this Certificate of `� oe CITY ' Tel.No. Exemption,you should become subject to the Workers'Compensation J.TO 10 INCLUSIVE EACH �/ provisions of the Labor Cade, you must forthwith comply with such '11 TO 40 INCLUSIVE EACH PPLICANTRMIT N Q 2/ s , provisions or this permit shall be deemed revoked. ,41 OR MORE BRANCH CIRCUITS EACH } LICENSED CONTRACTORS DECLARATION ADORESS3S�j 15 OR 20A,208V TO.277V LIGHTING EACH a 1 hereby affirm that 1'am licensed under provisions of Chapter 9 (commencing with Section 7000)of Division 3.of the Business and CITY T.I.No.tK(' 1.3 3,..1 3; Professions Cade.,and my license is in.full force and effect. RESIDENTIAL APPLIANCES.UP TO 3HP, I ICENSEOR Power Apparatus&Large Appliances. REG.NUMBER class.., Q /�j/— �/� G6 10 C License Number 5 zr aX Lid.Class Size&Type HP,KW,KVA,or KVAR DISTRICi NO. p� P OCESSED BY �. Up.to 8 incl. c�ldd LUjJ �,Lai! S`r�- ;Over 3 to 10 Incl. FINAL 0. CoMractar. ` .. ate ,03 3 DATE Z ❑ Over 10 to 50 Incl. am exempt.under Sec. Over 50 to 100 Incl. IZ��Q �..� VALIDATION B B.&P.C.for this reason. Over 100 _ BY .. Services,.Swbd.,.MCC&.Panelboards• , Date:. 15- Z y�. 0-.200 Amp.Under 600'V , Signatu 201'-1000 Amps Under 600 V El Over 1000 Amp.or Over 600 V Exemption for Reg.Maint..Elect SINGLE FAMILY { Temp.•Pov+er Pole&Appurtenances HOME OWNER-BUILDER DECLARATION y I hereby affirm that'I am/zempt from the Contractor's License.Law Sign with One Branch Circuit for the followingreason Section 7031.5, Business and Professions Additional 3i n Branch Circuits 3�'"I7 1667=52 6 5 Code): ❑ �'I,as owner of the property,will do the work and.the structure Misr.Conduits:&Conductors ITEMS, ,. _, e �; is-not intended or offered for sale'(Section 7044, Business Other(See Complete Fee Schedule) , j ' ^ !FAL and Professions Code). t. 5.2 CONSTRUCTION LENDING AGENCY n••-,~r- r hereby affirm that there is a construction.lending agency for the //J =�'"•'til: -' performance of the work for which this permit is issued (Sec.3097, PERMIT FEE (Sub-Total) - -w77. Civ.C.) 0 PLAN CHECKING FEE Lender's Name PERMIT ISSUING FEE a-31 t AN ''.•°:�I� LeAder's Address J�� ' 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 representatives of this County to enter upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE SIGNATURE.OF APPLICANT OR AGENT •DATE 11YOR9� ;OMPENSATION DECLARATION 7 DPW 3/67 I hereby.affips I have a certificate of consent to self ce-eoaa APpL1( PION FOR ELECTRICAL HERMIT O insure,.or a cerTITICare of Workers'Compensation Insurance, COUNTY OL _; ANGELES DEPT. OF PUBLIC WORKS or a ckiufied copy thereof_ (Sec. 3800, Lab. C.) • Poli No. 449° Company $T1k-T�' /�VAJD FOR APPLICANT TO FILL IN JOB , Certified copy is hereby furnished. New Residential Bldgs. &Pools EACH NO. FEE ADDRESS �g. O - � 5L Certified copy is filed with the county building inspec- 1 &2-Family, Sq. Ft. $ — $ LOCALITY L LIT�� tion department. Multi-family Sq. Ft. -- NEAREST CROSS 2 Residential Swimming Pools OWNERSOR T. S Date 7-a.-91 Applicant 'D � .�•'. , ,4 .r ' FIRM NAME I.DN kJe✓a CERTIFICATE OF EXEMPTION.FROM WORKERS' Outlets: Rec Light Sw.— MAIL OO T� OO COMPENSATION INSURANCE ADDRESS First 20 (This section need not be completed if the work involved byTotal No. Additional CITY IVO .,r Tel. No. _!&Cp J 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 permit is issued., I shall not employ any person in any manner Lighting Fixtures First 20 ADDRESS JZg,/ M so as to become subject to the Workers'Compensation Laws. $� g Additional Date Applicant Total No. I CITY N,5MRIJ)LE- Tel. No.'7 ra,)LQ NOTICE TO APPLICANT: 'If, after making this Certificate of Fixed Appliances Not Over 1 HP PERMIT r r 9 �• ; �APPLIOATION L a`LEC'(`il,4 Exemption;, you should become subject to the Workers' Range— Heater—..•.D.W. — Compensation provisions of the Labor Code, you must forth- ti' Oven — Dryer —W.M.— ADDRESS 118~0 N 6VE` Ste, with comply with such provisions or this permit shall be Top — FAU —W.H. — deemed revoked. Hood — Fan _Other— CITY ArN&IA. Xr4(e Tel. No.G O•c LICENSED CONTRACTORS DECLARATION LICENSE OR Disp. — Room Air Cond. — REG. NUMBER 6691LI Class.0-10 I hereby affirm that I am licensed under provisions-of Chapter 9 (commencing with Section 7000)of Division 3.of the Business Power Apparatus&Large Appliances DISTRICT NO. P ESSED BY O} and Professions Code,and my license is in full force and effect. �+ ' py Size&Type HP, KW, KVA, or KVAR i i d O ' License Number S&6ML_Lic. Class C-•ID Up to 1 Incl. FINAL V DATE E4E�•r Over 1 to 10 Incl. r Z- . Z VALIDATION Contractor 699i � Date .5-3A- `3 O Dt Over 10 to 50 Incl. FINAL U I am exempt under Sec. Over 50 to 100 Inc. BY W B.&P.C, for this reason �— Over 100 7 v CL Z Date: Services, Swbd.., MCC&Panelboards ► Z 0-200 Amp. Under 600 V Signature 201 - 1000 Amp. Under 600 V Exemption for Reg. Maint. Elect. Over 1000 Amp. or Over 600 V � SINGLE FAMILY Temp. Power Pole&Appurtepances ' HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit I hereby affirm that I am exempt from the Contractor's License Additional Sign Branch•Circuits �'�T° Law for the following reason (Section 7031.5, Business and g _ Professions Code): 31-1137 I?I' + T '❑ I, as owner of the property, will do Misc. Conduits&Conductors the work and the i �.T•: IM"', structure is not intended or offered for sale(Section 7044, Other(See Complete Fee Schedule)— _ Business and Professions Code). + l°ALL u+4 � 0I CONSTRUCTION LENDING AGENCYw ,F,'�{ ,:f I hereby affirm that there is a construction lending agency for - s the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) C11tiFt'7� (Sec. 3097, Civ. C.). PLAN CHECKING FEE Lenders Name I `0 PERMIT ISSUING FEE Q0tl�l-�it�;.la *'11',r0/�= Lender's Address '? 1 I certify that I have read this application and state that the TOTAL FEE $H�C>0 �� above information is correct. I agree to comply with all County ordinances and State laws regulating Electrical wiring, and I�DING �► of (Temp- �wtatives of this County to enter upon J t ove- lone pro oTinspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE 7-a3-C1I I I Sig-AWbrir of Permittee Date WORKERS'COMPENSATION DECLARATION DPw3/87 APPLICATION FOR ELECTRICAL PERMIT O I hereby affirm that I have a certificate of consent t 76AM3 self 76n6a3 insure, or a certificate of Workers'Compensation Insur, CE-8066 ince, 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 j JOB jt�� d� t -� ❑Certified co is hereb furnished. ADDRESS CC..�' 4 PY Y New Residential Bldgs. &Pools EACH NO. FE ❑Certified copy is filed with the count building in Pec- 1 &2-Famil S Ft. $ — $ LOCALITY LE Y 9 � P Y> q• �� tion department. Multi-family Sq. Ft, — NEAREST Date Applicant Residential Swimming Pools CROSS OWNER ST. OR JADDRESS RM NAME /9�/Q/0�,/ /✓G CERTIFICATE OF EXEMPTION FROM WORKERS' 'Outlets: Rec Light Sw._ MAIL COMPENSATION INSURANCE First 20 (This section need not be completed if the work involy d by Total No. Additional ITY I A,& ��f� fTeI. No. 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 0,&A 4,,o, permit is issued, I shall not employ any person in any Mali ner so as to become subject to the Workers'Compensation L Ws. Lighting Fixtures First 20 ADDRESS Additional Date Applicant Total No. CITY Di�rfi✓��Q/T �� t91. NOTICE TO APPLICANT: If, after making this Certificate of Fixed Appliances Not Over 1 HP PERMIT +f T,} s .Exemption, you ,should become subject to the Workers' Range— Heater—D.W. — APPLICATION Fi,.., eIr Compensation provisions of the Labor Code, you must forth- Oven — Dryer —W.M.— ADDRESS L;F0 j r�?• with comply with such provisions or this permit shall Hood — Fan —Other— be Top — FAU —W.H. — el t deemed revoked. - f CITY Tel. N.b.I'll-EINE LICENSED CONTRACTORS DECLARATION Disp, _ Room Air Cond. — LICENSE o I hereby affirm that I am licensed under provisions of Chop er 9 REG. NUMBER TOTAL Cla�3 2 (30 (commencing With Section 7000)of.Division 3 of the Bus!less Power Apparatus&Large Appliances DISTRICT NO. PRQP BY L" Y and Professions Code,and my license is in full force and a ect. �' -" Size&Type HP, KW, KVA, or KVARI!' Q License Number Lic. Class Up to 1 Incl. FINAL �� Contractor Date Over 1 to 10 Incl. �� J I d DATE VALIDATION 'r , Q Over 10 to 50 Incl, '� I FINAL [ )ii..�"I�IM01 1,22. ❑ I am exempt under Sec. Over 50 to 100 Inc. gYr } 3 =,� B.&P.C.'for this reason Over 100 �M: Services, Swbd., MCC&Panelboards Dater Z 0-200 Amp. Under 600 V Signature 201 - 1000 Amp. Under 600 V �� O Over 1000 Amp. or Over 600 V ❑ Exemption for Reg. Maint. Elect. SINGLE FAMILY 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 sand Additional Sign Branch Circuits Professions Code): ❑ I, as owner of the property, will do the work and the Misc. Conduits&Conductors structure is not intended or offered for sale(Section 7)44, Other(SemC lete Fee Sc edule)_ Business and Professions Code). �/ e% Y.s► �� O CONSTRUCTION LENDING AGENCY 977 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) Jr-- (Sec. 3097, Civ. C.). 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 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 uRon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date i