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Home My Public Portal About5821-5827 ROSEMEAD BLVD_Electrical__ V WOR COMPENSATION DECLARATION 720-W196A663 oPw.3%� APPLII TION FOR ELECTRICAL PERMIT O I,hereby affiri I have a certificate of consent to self CEG I. ..sure, or a cc-., to of.Workers'Compensation Insurance, COUNTY C. __S ANGELES DEPT. OF PUBLIC WORKS or c6certified co xL►�thereof(Sec. 3800, Lab. C.) C Q Poli No. `�� 'Company FOR APPLICANT TO FILL IN JOB ADDRESSVa 7 Certified co is hereby furnished. EACH NO. FEE PY Y ��.•��— New Residential Bldgs. &Pools y Certified copy 'is filed with the count b ' 1 &2-Family, Sq. Ft. $ — $ LOCALITY L4 C:I-r I tion department. Multi-family Sq. Ft. — NEAREST J Date rIr I Applicant Residential Swimming Pools CROSS ST. 5 OWNER OR C� ' FIRM NAME (O CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec��Light Sw:�L_ l� 4 ADDRESS Oo C7C GATS0� COMPENSATION INSURANCE First 20IV (This section need not be.completed if the work involved by Total No. Additional O G7 CITY �{�A✓G C Tel.,No.!� 6 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 mariner r. so as to become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS Total No. Additional CO Date Applicant CIN NQ Imr Tel. No a� J NOTICE TO APPLICANT: If, after .making this Certificate of Fixed Appliances Not Over 1 HP PERMIT —,'C I C_ Exemption, you should become subject to the Workers' Range— .Heater—D.W. — APPLICATION R C&INL E.( Compensation provisions of the Labor-Code, you must forth= Oven Dryer —W.M.— I„ ADDRESS Aa?b N -Avle- 51 r with .comply with such. provisions or this permit shall. be Top — FAU W.H. — deemed revoked. — CITY M 1�`f� Tel. No.(p .q Hood — Fan —Other_ LICENSED CONTRACTORS DECLARATIONp LICENSE R / f q _ O Dis _ Room Air Cond. — U- l '.; 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 8 Large Appliances DISTRICT NO. PME'11 I and Professions Code,and my license is in full force and effect. DSize&Type HP, KW, KVA, or KVAR License Number- b� /�� Lic. Class �� ,o+ Up to 1 Incl. FINAL c ••� Over 1 to 10 Incl. DATE VALIDATION Contractor!PRA -'��'� * Date- �� L+ Mtn Over 10 to 50 Incl. �� Z' y 1 U " FINALGt i a S I am exempt under Sec. Over 50 to 100 Inc. BY .t_,.., Over 100 I s+ul 1 i B.BP.C. for this reason _ Services, Swbd..,MCC 8 Panelboards (fie , 4 i i E L Z Date: d � 0-200 Amp.'Under 600 V Signature 201 - 1000 Amp. Under 600 V TOTAL _-2:40 m 60 Exemption for Reg..Nlaint. Elect. Over 1000 Amp. or Over.600 V CHECK i'f13a.iiLJ SINGLE FAMILY CHANGE HOME OWNER-BUILDER DECLARATION ' Temp. Power Pole&Appurtenances I hbreby affirm that I am exempt from the Contractors License Sign with One Branch Circuit Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits !]Ijt)ij—i�ljl]j '' `� tri:IrZ 1 Professions Code•): � O �i p,.� - ❑•i, as owner of the property, will do the work and,the Misc. Conduits&Conductors �� s i )`�1°°•-' structure is not intended or offered for sale(Section 7044, Other(See Complete Fee Schedule) , Business and Professions Code). 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) zog (Sec. 3097, Civ.C.). " PLAN CHECKING FEE .: :;;;. , ., Lender's Name I. % PERMIT ISSUING FEE Lender's Address I certify that I have read this application and state that the I TOTAL FEE above information is correct. I agree to.comply with all County ordinances and State laws regulating Electrical wiring, and e)UIL11NJkjG hereby authorize representatives of this County to enter upon IZ the a=men' property o 'nspection purposes. - _ SEE REVERSE FOR EXPLANATORY LANGUAGE FE Signature o ermi ee ate a ' ®' WORKS--" -�MPENSATION DECLARATION i• 78-883 10/81 /�PPLIC, ON-FOR ELECTRICAL PERMIT I hereby affirm th$ 3 a certificaCE-8086 /'�te of consent to self insure, or a certificate of' W Compensation Insurance, or a certified COUNTY OF L( VGELES BUILDINGAND SAFETY copy thereof(Sec.3806,Lab.C.) _ Policy NoJ CompanyS l*rG Fr✓6.21=2 FOR APPLICANT TO FILL IN/ JOB 1�J._ Certified'copy.ia hereby furnished. EACH' NO. FEE ADDRESS p(;Q New Residential Bldgs.&Pools ❑ 1 &:2-Family,Sq.Ft. $ — $ LOCALITY Certified copy is filed with the county building inspection department. Multi-family Sq.Ft. — NEAREST CROSS 3T. Date'`��+"�'��Applican " v Residential Swimming Pools OWNER OR FIRM NAME 7 CERTIFICATE OF EXEMPTION FROM-WORKERS' Outlets:Rec—Light Sw. MAIL . — COMPENSATION INSURANCE ADDRESS (This section need not be completed if=the work involved by the First 20 v permit Is-for.one hundred dollars.($100)or less.) Total No. Additional060 CI, Tel.,No. – I certify that.in the performance of the work for which this permit PLAN CHECK is issued, I shall not employ any person in any manner so as to i67) , APPLICANT become subject to the Workers'Compensation Laws. Lighjiag Ix res First 20 7Q ADDRESS + f er Additional o al No, CITY Tel.No. Date' Applicant Fixed Appliances of Over 1 HP NOTICE TO' APPLICANT: If, after making. this Certificate 'of PERMIT Exemption,you should become subject to the Workers'Co..mpensation Range_ Heater D.W. _ APPLICANT provisions of the Labor Code,,you must forthwith comply with such Oven _ Dryer_ W.M._ ADDRESS Q provisions or this permit shall be deemed revoked Top _ FAU _ WH. _ CITY yv7el.No.� jf–y� 011 Z LICENSED CONTRACTORS DECLARATION. Hood — Fan Other_ 1 hereby affirm that I am licensed under provisions of Chapter'9 LICENSE OR (commencing with Section 7000)of.Division 3 of the Business and Disp, — Room Air Gond. REG.NUMBER Claw. Professions'Code,and my license is in full force and effect. power Apparatus&Large Appliances' DISTRICT NO. f� PR SED BY P—/l Size&T pe HP,KW,KVA,or KVAR �t�® U License Number ffa� Lic.Class Up to 1 Incl. O C140 FINAL �__. �,, -'-7 Q Over 1 to 1.0 Incl. DATE, +� VALIDATION Contractor�C � ,� L �A Date—6a /� �1 Over 10 to•50.l6cl. 2.2,MAL FINAL ❑ 1 am,exempt under Sec. / Over 50 to 100 Inc. T BY W Over 100 �- B.&P.C.for this reason. fn ' Date: Services,Swbd.,MCC&Panelboards ® Z 0-200 Amp.Under 600 V, .Signature 201 - 10.00 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 a I hereby affirm that I am exempt from the.Contractor's License Lawadditional Sign Branch Circuits ( �`'T for the following reason(Section 7031.5,Business and Professions �7�+� .,r Code): •. 3,75. I 30 i Misc.Conduits&Conductors ❑ I,as owner of the property,will do the work and the.structure Other(See Complete Fee Schedule) Js.not intended dr offered for sale (Section 7044, Business. ► TO ! � .- Z75c and Professions Code). 00 CONSTRUCTION LENDING AGENCY CHECK = e I hereby affirm that there is a construction lending agency for the CHANGE ; o�I performance of the work for which this permit is issued(Sec.3097, PERMIT FEE (Sub-Total) Civ:'C.). PLAN CHECKING FEE f�fJIZ40 ]- f j 1 Lender's Name PERMIT ISSUING FEE f�j Lender's Address '14 ! Am 8°41. 1 certify that.I have.read this application and state that the above TOTAL FEE ,3ys information is correct.I agree to comply with all County ordinances ,f and State laws regulating Electrical wiring, and hereby authorize / representatives of this County to enter upon the above-mentioned L property lor inspection purpb s. SEE REVERSE FOR EXPLANATORY LANGUAGE ✓a�a-�� (gnat re of mittee Date " WORKERS'COMPENSATION DECLARATION 7&Ao19DPW3/67 APPLICATION FOR ELECTRICAL PERMIT O I hereby affirm that I have a certificate of consent to self CE insure, or a certificate of Workers'Compensation Insurance, 1 COUNTY OF LOS ANGELES h DEPT. OF PUBLIC WORKS or a certified copy thereof(Sec. 3800, Lab. C.) Policy No. Company i FOR:APPLICANT TO FILL IN IJOB ❑Certified copy is hereby furnished. EACH NO. FEE ADDRESS �. 18 1 �SLr M I:Ab QZ 'New Residential Bldgs. &Pools $ _ $ jLOCALITY t ❑Certified copy is filed with the county building inspec- 1 &2-Family, Sq. Ft. NEAREST T�1r+ C.i7 tion department. I Multi-family Sq. Ft. 1. !CROSS L/aF 111Jd•.f bi Date Applicant Residential Swimming Pools OWNER OR `, I .FIRM NAME Ci . .Kv CERTIFICATE OF EXEMPTION FROM WORKERS' i ('MAIL COMPENSATION INSURANCE Outlets: Rec Light Sw._ 'ADDRESS 0O OC I;` *t baa (This section need not be completed if the work involved by First CITY LTel. N 3 the permit'is for one hundred dollars•(5100)or less.) I Total No. Additional IIoll(r Cd. o. �] PLAN CHECK �s 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 I(ADDRESS so as to become subject to the Workers'Compensation Laws. g g J,ADDRESS C38 bAital AVLr Total No.— Additional Date Applicant Fixed Appliances Not Over 1 HP I'PERMITNOR el 6' Cd Tel. No. 'P7Z,22Z NOTICE TO APPLICANT: If, after making this Certificate of +APPLICATION Exemption; you should become subject .to the Workers' Range— Heater—D.W. — i Compensation provisions of the,Labor Code, you must forth- Oven — Dryer —W.M.— I ADDRESS with comply with such provisions or this permit shall be. Top — FAU —W.H. — deemed revoked. Hood — Fan —Other— IiCITY Tel: No. LICENSED CONTRACTORS DECLARATION . ;,LICENSE OR Disp. — Room Air Cond. rREG.NUMBER Class. I hereby-affirm that I.am licensed under provisions of Chapter 9 (commencing with Section 7000)of'. f 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: O pCL Size&Type HP, KW, KVA, or KVAR I d O License Number Lic. Class fI Up to 1 Incl. .FINAL 3307 531.9 Over 1 to 10 Incl. -DATE Contractor Date I. Over 10 to 50 Incl. OQ 0 (FINAL AVD LQN ❑. 1 am exempt under Sec. Over 50 to 100 Inc. FI TOTAL m 513 B.&P.C. for this reason Over 100. Services, Swbd., MCC&Panelboards CHECK' 531°62 Date: 0-200 Amp. Under 600 V Q 10 0 i® CHANGE o NJ Signature 201 - 1000 Amp. Under 600 V or El Over 1000 Am Ov r V Exemption for Reg. Wlaint. Elect. 5yZf i200�u/.. 00110-01301 11/14/91, SINGLE FAMILY Temp. Power Pole&Appurtenances /P Ojo 00, �q „- HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit 1 PSI. 5:04 1 hereby affirm that I am exempt from the-Contractor's License Law for the following reason:(Section 7031..5, Business and 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 7044, Other(See Complete-Fee Schedule)_ Business and Professions Code). '2 1O1. CQ Q kJJQ CONSTRUCTION LENDING AGENCY 27 L G G 20 2.�J0 Q I hereby affirm that there is a construction lending agency for /,J the performance of the work for which this permit is issued i PERMIT FEE (Sub-Total) (Sec. 3097, Civ. C.). 00 PLAN CHECKING FEE 15471 Q �.5 I- , Lender's Name PERMIT ISSUING FEE Lender's Address ' I certify that I have read this application and state that the TOTAL FEE [4 _ above information is correct. I agree to comply with all County Hi7 -- ordinances and State laws regulating Electrical wiring, and Su 11.D la 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 ®'