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Home My Public Portal About10300 LA ROSA DR_Electrical__ WORKERS'COMPENSATION DECLARATION CE-806 10,81 APPLICATION FOR ELECTRICAL PERMIT I hereby affirm that I have a certificate of consent to self CE-8066 ��pRX insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES /ti 76? C)Q BUILDING AND SAFETY / 7 �9 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 10300 7,a Rosa ❑ ❑ Certified copy is filed With the county building inspec- I & 2-Family, Sq. Ft. 1644 $ O — $ OCALITY Tempel City tion department. Multi-family Sq. FL — G NEAREST Residential Swimming Pools CROSS ST.Arden Date Applicant OWNER OR CERTIFICATE OF EXEMPTION FROM WORKERS' IRM NAMEMAR COMPENSATION INSURANCE Outlets: Re< Light_Sw._ ADDRESS 9088 Las Tunas (This section need not be completed if the work Involved by First 20 the permit is for one hundred dollars ($100)or less.) Total No. Additional CITY Temple City, Tel. Nc286-3636 certify that in the performance ofa PLAN CHECK the work for which this permit is issued, I shall not employ any person in any manner,7 APPLICANT Martin–Electric c so as to become subject to the Warkers' ompg9sotion Lo Lighting Fixtures First 20 ADDRESS 1560 N. Lassen 49 Total No. Additional Date R,3 gpplicantf4l?.Q'T/N Lrl./Bi,Q/ CITY Tel. No.Ontario - Fixed Appliances Not Over 1 HP PERMIT NOTICE APPLICANT: If, after making this Certificate of APPLICANT Martin Electric Exemption,n, 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 1560 N. Lassen with comply with such provisions or this permit shall be Top _ FAU —W.H. — deemed revoked. CITY Ontario Tel. No.98207880 LICENSED CONTRACTORS DECLARATION Hood _ Fan _ Other— I hereby affirm that I am licensed under provisions of Chapter 9 Disp. _ Room Air Cond. LICENSE REG. NUMBER 304982 CIOSSBER C-10 (commencing with Sectionof Division 3 of the Business Power Apparatus 8 Large Appliances DISTRICT NO. PROCESSED } and Professions Code, and myy license is in full force and effect, ppd 30�98� Size & Type HP, KW, KVA, or KVAR O License Number Lic. Class /l0 Up to 1 Incl. FINAL 2 1J /lpn 7/.✓ IFLEe 116 ��– 49'_k,3 Over 1 to 10 incl. DATE //r�/ VALIDATION 09 Contractor ate Over 10 to 50 Incl. FINAL V ❑ I am exempt under Sec. Over 50 to 100 Inc. BY W B.&P.C. for this reason Over 100 Z _Date: Services, SWbd., MCC & Ponelboards / 0 - 200 Amp. Under 600 V (i/ C 9 S� 4 6 93.2 A Signature / c( 201 - 1000 Amp. Under 600 V ❑ Exemption for Reg. Mainz. Elect. Over 1000 Amp. or Over 600 V 9 a o o e o 2 SINGLE FAMILY Temp. Power Pole & Appurtenances .2 -.- 7626 HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit o ^ c 7 E 26 u 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): –8 3 ❑ 1, 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). 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) (Sec. 3097, Civ. C.). PLAN CHECKING FEE Lender's Name PERMIT ISSUING FEE 1 50 Lender's Address 1 certify that I have reod'this application and stale that the TOTAL FEE above information is correct. I agree to comply with oil 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 7�J J6,� �. /J-ice Signature of Permittee C7L Date l S q O fi{e � (% Ees WOrm that DECLARATION CE"�6G 10/81 APPLICATION FOR ELECTRICAL PERMIT t I hereby affirm That I have a certificate of consent to self insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY �D j or a certified copy thereof (Sec. 3800, Lab. C.) Policy No. Company FOR APPLICANT TO FILL IN I JOB' Certified copy is hereby furnished. New Residential Bldgs. 8 Pools, EACH NO. FEE ADDR SS entified copy is filed with the county building ins ec- 1 & 2-Family, Sq. Ft. $ — $ LOCALITY NEAREST tion department. Multi-family Sq. Ft. CROSS ST. _ Date $�°s Applica q}/�T-"" / , Residential Swimming Pools OWNER OR ^ FIRM NAME ?L Gi+' CERTIFICATE OF EXEMPTION F M WOK Outlets: RecLightSw._ 'M''°'IL COMPENSATION INSURANCE ADDRESS/ This section need not be completed if the work involved b First 20 n ( P Y Total No. CITY K Tel. the permit is for one hundred dollars ($100)or less.) Additional Gi4�� I certify that in the performance of the work for which this PP PN APPLICANT permit is issued, t shall not employ any person in any manner so as to become subject to the Workers'Compensation Lows. Lighting Fixtures First 20 ADDRESS Total No. Additional CITY Tel. No. Dote Applicant Fixed Appliances Not Over 1 HPPERMIT NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT 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 with comply with such.provisions or this permit shall be Top — FAU —W.H. CITY Tel. No. deemed revoked. Hood _ Fan _Other_ LICENSED CONTRACTORS DECLARATION LICENSE OR hereby affirm that I am licensed under provisions of Chapter 9 Disp. _ Room Air Cond. REG. NUMBER SSL-'G/ Class. . (commencing with Section 7000) of Division 3 of the Business .DISTRICT NOPROCESSED BY Power Apparatus 8 Large Appliances �• and Professions Code,and my license is in full force and effect. ^� /�' Q Size 8 Type HP, KW, KVA, or KVAR 2 ' O License Number �'-'J?6/ L,icc.. Class x& Up to 1 Incl FINAL V Contractor / e 6 —7- 6� Over 1 to 10 Incl. DATE / :�� VALIDATION O Over 10 to 50 Incl.. FINAL F-1am exen t un (•� ~ / rc. Over 50 to 100 Inc. BY u. •,t B.BP.C. for this reason Over 100 Z Date: Services, Swbd., MCC 8 Ponelboards , 0 -200 Amp. Under 600 V Signature 201 - 1000 Amp. Under 600 V ❑ Over 1000 Amp. or Over 600 V Exemption for Req. Mainz. Elect. � � �2.6 1,4 A SINGLE FAMILY Temp. Power Pole 8 Appurtenances �-'5 HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit 1 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 2 ° ° 4 050 Professions Code): - 4050P2 1, as owner of the property, will do the* Misc. Conduits 8 Conductors ° work and the structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ ► 7044, Business and Professions Code). 0,6.0 87 8 3 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) 3O A (Sec. 3097, Civ. C.). PLAN CHECKING FEE Lender's Nome PERMIT ISSUING FEE 1 Lender's Address I certify that I have read this application and state that the TOTAL FEE yQr 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 pro erty For specti on purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE_15 } /' ig nature er ' a Dote _ olv-",, -- 47,- J