HomeMy Public PortalAbout10315 LA ROSA DR_Electrical__ DEC
TION
WORKERS'that
t I have
a certificate
cafe of corse CE 863 IO/BI APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self CE806G
insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
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. 8 Pools EACH NO. FEE ADDRESS 10315 La Rosa
❑ 1 8 2-Family, LOCALITY
Certified copy is filed with the county building inspec- y, Sq. Ft. 1644 5 — $ Temple Cit
lion deportment. Multi-family Sq. Ft. — NEAREST
CROSS ST, Arden
Residential Swimming Pools OWNER OR
Date Applicant FIRM NAME Fairhaven-Dev l0 TBen'CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec_LightSw._ MAIL
COMPENSATION INSURANCE ADDRESS 9088 Las Tunas
This section need not be completed if the work involved b First 20
( tiP T Total No. Additional CITY Temple CityTel. No.286-3636
the permit is for one hundred dollars ($100)or lets.)
I certify that in the performance of the work for which this PLAN CHECK Martin Electric
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 1560 N. Lassen
Total No. Additional
�],,// - �, CITY Ontario Tel. No.982-7880
Date Applicant�_ z4n Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers' Range_ Heater—D.W. — APPLICANT Martin Electric
Compensation provisions of the Labor Code, you must forth- Oven _ Dryer _ W.M.— ADDRESS 1560 N. Laszen
with comply with such provisions or this permit shall be Top _ FAU —W.H. —
deemed revoked. CITY Ontario Tel, Na.982-7880
LICENSED CONTRACTORS DECLARATION Hood _ Fan _Other—
Disp. Room Air Cond. LICENSE Class.
I hereby affirm that I am licensed under provisions of Chapter 9 REG. NUMBER 304982 C-10
(commencing with Section 7000) of Division 3 of the Business DISTRICT NO. PROCESSED BY
and Professions Code,and m license is in full force and effect. Power Apparatus 8 Large Appliances -5--,
( '
�/ Y � -,� Size 8 Type HP, KW, KVA, or KVAR' J i O Q
License Number., 0 / ��� Lic. Classes Up to 1 Incl. FINAL V
Hlae;rt tri< �r�t��X2 c? Over I to 10 Ind. DATE Z/ 139
VALIDATION Q
.Contracto Over 10 to 50 Incl. J - V
F1FINAL
I am exempt under Sec. Over 50 to 100 Inc. BY W
IL
B.BP.C. for this reason Over 100 W
Services, Swbd., MCC 8 Ponelboards ► ?
Date: 0 -200 Amp, Under 600 V
Signature 201 - 1000 Amp. Under 600 V
❑ Exemption for Reg. Mount. Elect. Over 1000 Amp. or Over 600 V
SINGLE FAMILY Temp. Power Pole 8 Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit 4 0 9.3 A
I hereby affirm that I am exempt from the Contractor's License Additional Sign Branch Circuits f)
Law for the fallowing reason (Section 7031.5, Business and - 0 o e - 2
Professions Code): 2 ^ 0 6 8 0 2
❑ I, as owner of the property, will do the work and the Misc. Conduits 8 Conductors _
structure is not intended or.offered for sale (Section Other (See Complete Fee Schedule)_ ' o - 0 68 0 2�
7044, Business and Professions Code),
a
CONSTRUCTION LENDING AGENCY 0,80 1 -83
1 hereby affirm that there is a construction lending agency for I
the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) S
(Sec. 3097, Civ. C).
PLAN CHECKING FEE _
Lender's Name
PERMIT ISSUING FEE 10 50
Lender's Address p
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 taws regulating Electrical wiring, and
hereby authorize representatives of this County to enter upon -
the above-me boned property for ' pection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee V Date