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HomeMy Public PortalAbout10305 LA ROSA DR_Electrical__ WORKERS' COMPENSATION DECLARATION IDiBt APPLICATION FOR ELECTRICAL PERMIT I hereby affirm that I have a certificate of consent to self CE-8066 //�� Insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES 7-42, BUILDING AND SAFETY or a certified copy thereof (Sec. 3800, Lab. C.) Policy No. Company FOR APPLICANT TO FILL IN JOB ADDRESS 10305 La Rosa Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ❑ I & 2-Family, LOCALITY Temple Cit Certified copy is filed with the county building inspec- Y� 59� Ft. f 9VH $ 03 — $ P y tion deportment. Multi-family \ Residential Swimming NEAREST mmm CROSS ST. Ardening Pools OWNER OR ' Date Applicant FIRM NAME a' CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec_Light_Sw._ MAIL COMPENSATION'INSURANCE ADDRESS 9088 E. Las Tunas s section neenot completed if the work involved b First 20 (Thitd t b P T the permit is for one hundred dollars ($100)or less.) Total No. Additional CITY Temple City Tel, No 286-3636 1 certif that in the erformance of the work for which this PLAN CHECK Y P APPLICANT Martin Electric permit is issued, I shall not employ any person in any manner so as to become subject to the Workers'Cnsation Laws. Lighting Fixtures First 20 ADDRESS 1560 N. Lassen �_1 Total No. CITY Ontario rel' N°' 982-7880 Date , aZ-��pplicant/r� ompeAdditional xed Appliances Not Over 1 HP PERMIT NOTICE TO APPLICANT: If, after making t is Certificate of APPLICANT Martin Electric 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 1560 N. Lassen with comply with such provisions or this permit shall be Top _ FAU —W.H. - CITY Tel. No. deemed revoked. Hood _ Fan _Other— Ont Ontario 9$2-7$$0 LICENSED CONTRACTORS DECLARATION LICENSE OR f hereby affirm that am licensed under provisions of Chapter 9 Disp. — Room Air Cond. REG. NUMBER 304982 Class. C-10 (commencing with Section 7000) of Division 3 of the Business DISTRICT NO. FIR C SSED BY and Professions Code,and my license is in full farce and effect. Power Apparatus& large Appliances _ �J I a Size&Type HP, KW, KVA, or KVAR' a;5. Qa v License Number d© / /OOc Lic. Class C /0 '- J�� �� y/�' p Up to 1 Incl. FINAL Coniracidrr� ""'' �r�i��ute 7—C2 / �3 Over I to 10 Incl. DATE '�p VALIDATION 0 ❑ Over 10 to 50 Ind. FINAL - V 1 am exempt under Sec. Over 50 to 100 Inc. BY _"� '.,--'�j W BAP.C. for this reason Over 100 z Dote. Services, Swbd., MCC& Paneiboords 0 -200 Amp. Under 600 V Signature 201 - 1000 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 I hereby affirm that I am exempt from the Contractor's License Additions h5i n Branch Circuits Law for the following reason (Section 7031.5, Business and e Professions Code)' ❑ I, as owner of the property, will do the work and the Misc. Conduits &Conductors # 0 0 o a e 2' structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)— , 2 n - 7.7.91 , 7044, Business and Professions Cade). CONSTRUCTION LENDING AGENCY a n o TT 9. z 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) G Y 0 6 0 7 -8 3 (Sec. 3097, Civ. C.). PLAN CHECKING FEE Lender's Name PERMIT ISSUING FEE 10 5 Lender's Address �/ I certify that I have read this application and state that the TOTAL FEE -17 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-men .tined property for i ection purposes. _ SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee 67 Dat� � e' Wm that I have a COMPENSATIONDECLARATION78-663 ,D,B, APPLICATION FOR ELECTRICAL PERMIT _ 1 hereby affirm that I have a certificate of conser�to self insure, CE-806G or a certificate of WorkersCompensation Insurance,or-a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY copy thereof(Sec.3800.Lab IC.)' • Policy No. Company 'FOR APPLICANT TO FILL IN - JOB Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADDRESS /0305 [A RASA ITY LA. Certified copy is filed with the county building inspection 1 & 2-Family, Sq.Ft. $ — $ LOCALITY department. Multi-family Sq.Ft. — NEAREST CROSS ST. Residential Swimming Pools OWNER OR, Date Applicant FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' MAIL ' Outlets:Red J_ Light � Sw. — COMPENSATION INSURANCE 1 n ADDRESS - } (Trines for need not be completed if the work involved-by the First 20 permit is for one In dollars($100)or less.) Total No. SA Additional CITY s .. Tel.No. -, I certify that in the performance of the work dor which this permit PLAN PLANCHET CHECK 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 tl ADDRESS Additional Total No.� 'CITY - Tel.No. Date - Applicant Fixed Appliances Not Over 1 HP NOTICE TO APPLICANT: If, after making this.Certificate of PERMIT Exemption,youshould become subject to the Workers'Compensation Range_ Heater_ D.W. _ APPLICANT .provisions of the Labor Code, you must forthwith comply with such Oven _ Dryer — W.M._ ADDRESS provisions or this permit shall be deemed revoked. Top — FAU W.H. CITY Tel.No. LICENSED CONTRACTORS bECLARATION Hood — Fan Other_ I hereby affirm that I am licensed under provisions of Chapter 9LICENSE OR (commencing with Section 7000) of Division 3 of the Business and .Dlsp. — Room Air Cord. —. REG,NUMBER - Class. Professions Code,and my license is in full force and effect. Power Apparatus&Large Appliances DISTRICT NO. ^ PRo sED By Size& Type HP,KW,KVA,or KVAR U Ha License Number Lia Class _ Up to 1 Inc. FINAL .n V Over 1 to 10 Incl. DATE yl// VALIDATION 0 Contractor Date Over 10 to 50 Incl, If— E] FINAL am exempt under Sec. Over 50 to 100 Inc. BY W Over 100 d BARD.for this reason (n DateServices,Swbd.,MCC& Panelboards , Z : 0-200 Amp.Under 600 V Signature - 201 - 1000 Amp.Under 600 V Over 1000 Amp. or Over 600 V . xemption for Reg.Maint.Elect, SINGLE FAMILY Temp.Power Pole& Appurtenances HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit ACCT.t 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 - „Q7 'JQ�'�r Code): ,�,/' Mac.Conduits & Conductors _ 1 ITEMS L� I,as owner of the property,will tlo the work and the structure TOTAL ' 20 .75 is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule)'_ ► and Professions Code). cHEc►; 29.7s CONSTRUCTION LENDING AGENCY nuA.'rc .�� I hereby affirm that there is a construction lending agency,for the CWAI�G performance of the work for which this permit is issued(Sec.3097, PERMIT FEE (Sub-Total) Civ.C.). rrr1 PLAN CHECKING FEE 0000-0001 12/29/09 Lender's Name PERMIT ISSUING FEE , 7K2 1 AM11:53 Lender's Address OCO 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 Permute Date COUNTY OF LOS ANGELES TEMPLE CITY # 0508 ELECTRICAL PERMIT DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS EL 0508 0504070015 BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 PHONE: (626) 285-0488 EXT: L G L T : SA Dom- BUILDING ADDRESS: 1'R: 37580 LT: 1 - 10305 LA ROSA DR FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: TEMP CA 917803402 ASSESSOR INFORMATION N NEAREST CROSS STREET: ARDEN 8585-018-041 Al PERMIT ISSUANCE FEE 27.75 THOMAS PAGE: 597 GRID: B4 LOCALITY: TEMPLE CITY, C G1 OUTLETS-LGT,SW,RECP 4.00 OUT 7.80 N-AN-f G2 LIGHTING FIXTURES 3.00 LGT 5.85 ISSUED ON: PROCESS O BY: PLAN BY: EXPIRES ON: TOTAL FEES 41.40 04/07/05 JK - 10/04/05 OWNER: TEL. NO: FINAL DATE FINAL BY: CODE: NOYES, JOSEPH (626) 443-4023- m_ 5- 10305 LA ROSA DR TEMP 917803402 DESCA 0OF 96RK ELECTRICAL FOR BATHROOM REMODEL APPLICANT: TEL. BUCCOLA (626) 287-1131- 8812 LAS TUNAS DR SPECIAL CONDITIONS: SAN GABRIEL CA 91776 CONTRACTOR- TEL. NO: APPROVALS DATE INSPECTOR SIGNATURE L & W KITCHEN & BATHS (626) 287-1131- 8812 LAS TUNAS DR. LIC. NO TEMPORARY POWER POLE SAN GABRIEL, CA 91776 2053448 UNDERGROUND CONDUIT 1 ARCHITECTNG NEER: TEL. O: UFER GROUND LIC. NO: ROUGH CONDUIT i ROUGHI R G MAIN WATER LINE �T PLASTIC YIN METAL YIN UTILITY COMPANY 0 I D REPORT ID: DPR265 ROUTE TO: BS0508