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HomeMy Public PortalAbout10330 LA ROSA DR_Electrical__ WORKERS' shot have COMPENSATIONDECLARATION of corse CE-806 ID,Br APPLICATION FOR ELECTRICAL. PERMIT I hereby affirm That I have a certificate of consent Io self CE-8066 insure, ar o certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY or a certified copy thereof (Sec. 3000, Lab. C.) Policy No. Company FOR APPLICANT TO FILL IN$ JOB ODRESS 10303 La Rosa Certified copy is hereby furnished. New Residential Bldgs. 8 Pools EACH NO. FEE ❑ LOCALITY Certified copy is filed with the county building inspec- 18 2-Family, Sq. Ft. 1 Q1( — $ Temple City tion department. Multi-family Sq. Ft. — NEAREST CROSS ST. Arden Date Residential Swimming Pools OWNER OR Applicant FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: RecLight_Sw._ 'MAIL COMPENSATION INSURANCE First 20 ADDRESS 9088 Las Tunas (This section need not be completed if the work involved by Total No. Additional CITY Temple City Tel. No. 2$6_3636 the permit is for one hundred dollars ($100)or less.) - that in the performance of the work for which this PLAN CHECK I certify P 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 Total No. Additional Dote//"--57-93 Applicant CITU Ontario Tel. No982-7880 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 _OtherCITY 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 Class.C_10 (commencing with Section 7000)of Division 3 of the Business DISTRICT NO. PROCESSED BY and Professions Code,and my license is in full force and effect. Power Apparatus 8 Large Appliances �x� ,�` > Size 8'Type HP, KW, KVA, or KVAR- �V ©r/ Q License Number 30WIF-9- Lic. Class C_10 .Up l0 1 Incl FINAL �j W ContractorApV,.QT2U �� ' ad'Iey�' //�e2�'s�,� Over 1 to 10 Ind. - DATE /� �A�i VALIDATION 0 Over 10 to 50 Incl. FINAL V ~ ❑ I am exempt under Sec. Over 50 to 100 Inc. BY .y �i.K f IL B.BP.C. for this reason Over 100 Z Date: Services, Swbd., MCC 8 Panelboards , 0 -200 Amp, Under 600 V Signature 201 - 1000 Amp. Under 600 V 170A ❑ y ' Exemption for Reg. Moint. Elect. Over 1000 Amp. or Over 600 V 2 SINGLE FAMILY Temp. Power Pole 8 Appurtenances HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit 2 ° ° 7756 1 hereby affirm that I am exempt from the Contractor's License 7 7 h Circuits rcu Additional Sign Branch a ° x5 5 6 Law for the following reason (Section 7031.5, Business and . Professions Code): ❑ I, as owner of the property, will do the work and the Misc. Conduits 8 Conductors 1 1,2 9-23 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 10 0 Lender's Address I certify that I have read this application and state that the TOTAL FEE r 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 in ection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE P'3 Signature of Permi free Date