HomeMy Public PortalAbout10320 LA ROSA DR_Electrical__ DEC
TION
76A663
WORKERS'that
t I have
a certificate
cafe of corse CE-806 10,91 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 T( BUILDING AND SAFETY
or a certified copy thereof (Sec. 3800, Lab. C.) �w///
Policy No. Company FOR APPLICANT TO FILL IN ADDRESS 10320 La Rosa
Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE
❑ Certified copy is filed with the county building inspec- 1 & 2-Fam A};Sq. H. 1916 $ — $ 6706 LOCALITY Temple cit
tion department. Multi-family Sq. Ft. — -NEAREST
CROSS$T. Aiden
Date Applicant Residential Swimming Pools OWNER OR
FIRM NAME Fnirhnvpn Development
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec_LightSw._ MAIL
COMPENSATION INSURANCE ADDRESS 9088 Las Tunas
(This t be completed if the work involved b First 20
( s section neenoP T Total No. Additional CITY Tempel City Tek No 286-3636
the permit is For one hundred dollars ($I00)or less.)
I certify that in the performance of the work for which this APPLICANT Martin Electric
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
Additional
Date//-aF CH Applicant Total No. CITY Tel. No.
fixed Appliances Not Over I HP PERMIT
Ontario 982-7880
NOTICE TO APPLICANTS If, after making this Certificate of APPLICANT Martin Electric
Exemption, you should become subject to the Worker Range_ Hooter—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. Hood _ Fan _ Other— CITY Ontario Tel.-No.982-7880
LICENSED CONTRACTORS DECLARATION LICENSE OR
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. Roam Air Canal. REG. NUMBER 304982 Class(,'-10
(commencing with Section 7000) of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO. f� PROCESSED BY
and Professions Code, and my license is in full force and effect. Type �O U /�I*7- n a.
O
Size &T e HP, KW, KVA, or KVAR' U l"-1 L(�
License Number JC c/ qS--X Lic. On. 6-0 IiQ Up to 1 Incl. FINAL W
M �T7� ��, Over I to 10 Incl. DATE f z . Z'7,� '� VALIDATION O
Contracted T Over 10 to 50 Incl. FINAL 1-
❑ I am exempt under Sec. Over 50 to 100 Inc. BY G..-e�,� W
B.&P.C. for this reason Over 100 Z
Date. Services, Swbd., MCC & Ponelboards ,
0 - 200 Amp. Under 600 V
Signature 201 - 1000 Amp. Under 600 V '
❑
Exemption for Reg. Maint. Elect, Over 1000 Amp. or Over 600 V
,971 69 A
SINGLE FAMILY Temp. Power Pole &Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit Ito o'o - 2
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 u -7 7.5 6
Professions Code):
❑ I, as owner of the property, will do the work and the Misc. Conduits &Conductors u�o -.7175 6 u
(
structure is not intended or offered for sale Section Other (See Complete Fee Schedule)_ ►
7044, Business and Professions Code). ,) 1,2 0 7 8 O
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
I certify that I have read this application and state that the I TOTAL FEE 1
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 property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
�✓j�.�. r -ate b3
Signature of Permittee Dote ,