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Home My Public Portal About5551-5551 1/2 SANTA ANITA AVE_Electrical__ t WORKERS'COMPENSATICiN DECLARATION 76A663 10/81 AP L��CAVOII`C.I FOR ELECTRICAL PERMIT I hereby„p ffirm that ,l•have a certificate of consent to self CE406G m ti�S h ; insure, ot`a certificate of Workers'-Com pensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY or a certified copy.thereof(Sec. 3800, Lab. C.) �Policy No. WC6471733ompany Homeland Ins. FOR APPLICANT TO FILL IN JOB Certified co is hereby furnished. EACH rNO. FEE ADDRESS 5551 Santa ANita PY Y New Residential Bldgs. Pools LOCALITY Certified copy is filed with the county building inspec- 1 &2-Family, Sq. Ft. $ $ 56 .6.8 T:em le Cittion department. Multi-family Sq. Ft. NEAREST CROSS ST. Date 04/01/87 Appl• Residential Swimming Pools OWNER OR FIRM NAME San Gabriel Properties CERTIFICATE OF E PTION FROM WORKERS' Outlets: Rec Li ht Sw._ MAIL g ADDRESS 217 W. Las Tunas G COMPENSATION INSURANCE ;\ h First 20m,',-,.�.•'� '' (This section need not be completed if the work involved by • 'r'. ,•a� ` CITY San Gabreil Tel. No. ---------- Total No: Additional•',. ,,. the permit is for one hundred dollars($100)or less.) ;� :,.• v ,. �_ PCAt4 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 so as to 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 PERMIT NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT Cobine Electric Co. Inc. 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 1607 Chestnut St. with comply with such provisions or this permit shall be Top FAU W.H. — deemed revoked. Hood CITY Alhambra Tel. No. 282-0315 �"Fan _Other_ LICENSED.CONTRACTORS DECLARATIONLIC SE OR I hereby affirm that I am licensed under provisions of Chapter 9 Disp. -14-Room Air Cond. 17 • 5 O RK. NUMBER 229847 Class. C10 (commencing with Section 7000)of Division 3 of the BusinessPower Apparatus&Large Appliances /DISTRICT NO. OC ED BY and Professions Code,and my license is in full force and effect. Q Size&Type HP, KW, KVA, or KVAR' f� License Number 229847 Lic. Class CIO FINAL %#Up to 1 Incl. 1 O <V a Over 1 to 10 Incl. DATE- � VALIDATION 0 Co ate 11/30/87 Over 10 to 50 Incl. FIN UI am exempt under Sec. Over 50 to 100 Inc. BY IL B.&P.C. for this reason Over 100 U) Services, Swbd., MCC&Ponelboards Date: 0 -200.Amp. Under 600 V Signature 201 -1000 Amp. Under 600 V ElExemption 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 Additional.Sign Branch Circuits Law for the following reason (Section 7031.5, Business and Professions Code): ❑ I, as owner of the property, will do the work and the M.sc. Conduits&Conductors structure is not intended or offered for sale (Section Other(See Complete Fee Schedule)- 7044, Business and Professions Code). X 5 5 7.6 A CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for 14r o 0 0 0 0 2 the performance of the work for which this permit is issued PERMIT-FEE (Sub-Total) 0 0 6 7 (Sec. 3097, Civ. C.). i /• 18 Tokai Bank of. C aliforia PLAN CHECKING FEE ,rib 0 0 o 6 7,•1 8 C5 Lender's Name PERMIT ISSUING FEE 10 .5y � 1,O b-8 6 Lender's Address 534 W. 6th 'St. , LA 1 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 upon 6 / • 1 Q the above;Mgntioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE/03/86 1gnature of ermittee Date r WORKERStCOMPENSATION DECLARATION 76Aw 1o�e.1 ni�ii ��j i�� n I hereby"affirm that I have a certificate.of'consent to self' CE`8� ,. AlJ"lrL� CA IJ 00N FOR ELEOROCAL� PERMIT .insure, of d'certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY or'a certified copy thereof (Sec. 3800; Lab. C.) Policy Na. WC647173 o -pony Homeland Ins.' a FOR APPLICANT TO FILL IN IDB Certified copy is hereby furnished. New Residential Bldgs. &Pools EACH NO. FEE. ADDRESS 5551 Santa Anita Certified copy is filed.with the county building inspec-. 1 &.2-Family, Sq. Ft. $ — $ 69 4 LOCALITY Teml .le City tion department. Multi-family Sq. Ft. — NEAREST -•� � CROSS ST. Date 04/0.1/87 A Residential Swimming Pools OWNER OR p + FIRM NAME San Gabriel -Pro erties - CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw._ ` t IL COMPENSATION INSURANCE \ ADDRESS 217 W. Las Tunas Dr. G First 20 ,. (This section need not be completed if the work involved by Total No. • d' CITY Tel. NQ,_________ the permit is for one hundred dollars($100)or less:) Addition • . _ San Gabriel • pl,,, . .PLAkCCHECK 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 so as to 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 PERMIT NOTICE TO APPLICANT: If; after making this Certificate of X APPLICANT Cobine Elertrie. Co. Inc Exemption,, you should become subject to the Workers' Range_ Heater_D:W. Compensation provisions of the Labor Code, you must forth- Oven x Dryer .—W.M.— ADDRESS 1607 Chestnut St. with comply with such provisions or this permit shall be Top FALI W.H. — deemed revoked. CITY Alhambra Tel. No.282_0315 LICENSED CONTRACTORS DECLARATION Hood Fan _Other_ Dis Room Air Gond. — �` 17 5. LICENSE M 229847 Class.. C 10 I hereby affirm that I am licensed under provisions of Chapter 9 p' REG. NUMBER (commencing with Section 700.0.)of Division 3 of the Business DISTRICT NO.. P ED BY and Professions Code,and my license is iri full force and effect. Power &Large Appliances 6- Size&Type HP, KW, KVA; or WARO License Number 229847 Lic. Class C10FINAL W Up To 1 Incl. 1'1/30/87 Over 1 to 10 Incl. DATE �� VALIDATION @s Co Date . Over 10 to 50 Incl. O IIIFIN y 1 am exempt under Sec.A53R Over 50 to 100 Inc. BY _ B.&P.C. for this reason Over 100 Date: Services, Swbd., MCC&Panelboards D 0 -200 Amp, Under 600 V 1. 15 Signature 201 - 1000 Amp. Under 600 V ElExemption 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 Additional Sign Branch Circuits Law for the following reason .(Section 7031.5, Business and 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 Other(See Complete Fee Schedule)_ 7044., Business and Professions Code). D 5 5 7.7 A CONSTRUCTION LENDING AGENCY #,0 0 0 0 0 2 1 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) I 0 - 79.90 (Sec. 3097, Civ. C.). PLAN CHECKING FEE 6 .0 0 - 79,905 U Lender's Name Tokai Bank Of California - Lender's Address 534 W. 6th St. . LA PERMIT ISSUING FEE 1 0. 0 0,1 0 6-g 6 I certify that I have read this application and state that the TOTAL FEE 9 1 above information is correct. I agree to comply with all County �7 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 10/03/86 --ri-gnature o Permittee Date