HomeMy Public PortalAbout10325 LA ROSA DR_Electrical__ WORKERS'COMPENSATION cafeDECLARATION
once JE-806 10/87 APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self CE-806G
insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES T C' BUILDING AND SAFETY
or a certified copy thereof (Sec. 3800, Lab. C.) !
Policy No. Company FOR APPLICANT TO FILL IN JOB
ADDRESS 10325 La Rosa
Certified copy is hereby furnished. New Residential Bldgs. 8 Pools EACH NO. FEE
❑ Certified coy g.' p 1 & 2-Family, q. LOCALITY
copy is filed with the count huildin inspec- Y� S t. 91 h 8 — $ - Temple City
tion department. � Multi-family$q, Ft. 'NEAREST
Residential Swimming Pools CROSS ST. Ardpn
OWNER OR
Date Applicant FIRM NAME Fairhaven Development
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Re<_Light_$w._ MAIL
COMPENSATION INSURANCE First 20 ADDRESS 9088 Las Tunas
(This section need not be completed if the work involved by ictal No. Additional CITY Temple Cit Tel. No. 2 _
the permit is for one hundred dollars ($100)or less.) PIAN CHECK
3636
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, Ming Fixtures First 20 ADDRESS 1560 N Lassen
�p �'17/J� •rye Total No. Additional
CITY
� �C`C/W rY Ontario rel. No982-7880
Date Applicant r fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, after making this 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. --
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. _ Room Air Cond. REG. NUMBER 304982 Closs.C_10
(commencing with Section 7000) of Division 3 of the Business power Apparatus& Large Appliances DISTRICT NO. PR ED BY �,
and Professions Code,and my license is in full force and effect. f d
G d-10Size &Type HP, KW, KVA, or KVAR' J r Y O
License Number 20y 9p � Lic. ClassesFINAL V
Up to 1 Incl.
/�/�� be
Yiy OXAC
^ Over 1 l0 10 Incl. DATE // VALIDATION O
Controctor O�` bate 7—a9—Fs,3 - -
Over 10 to 50 Incl. FINAL ~
❑ 1 am exempt under Sec. Over 50 to 100 Inc. BY JIM
B.&P.C. for this reason Over 100 r/1
Services, Swbd., MCC& Ponelboards , ?
Date: 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 r 4 0 9, 2 A
I hereby affirm that I am exempt from the Contractor's License Branch Circuits l Sign n
Law for the following reason (Section 7031.5, Business and g o o e e a 2
Professions Code):
❑ I, as owner of the property, will do the work and the Misc. Conduits &Conductors o 0 7 75 0
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)— , o-o e
7044, Business and Professions Code). 775'G
CONSTRUCTION LENDING AGENCY 08-01 —83
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 10 50
Lender's Address
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 laws regulating Electrical wiring, and -
hereby authorize representatives of this County to enter upon '
the above-mentioned property for inspect', n purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
2!—,:2 9
Signature of Permittee Date