HomeMy Public PortalAbout10335 LA ROSA DR_Electrical__ WORKERS'COMPENSATION cafeDECLARATION
corse CE-66 loiet 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 C. BUILDING AND SAFETY
or a certified copy thereof (Sec. 3800, Lab. C.)
Policy No. Company FOR APPLICANT TO FILL IN` JOB
ADDRESS 1
926 $ — $Certified copy is hereby furnished. New Residential Bldgs. & Pp EACH NO. FEE
❑ Certified copy is filed with the county building inspec- - I & 2-Family, Sq. Ft, 1 67 471— LOCALITY Temple Cit
tion department - Multi-family Sq. Ft. — 'NEAREST
CROSS ST. Arden
Date Applicant FIRM
Swimming Pools 'OWNER OR
IRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light_Sw._ MAIL
COMPENSATION INSURANCE ADDRESS 9088 Las Tunas
Thitibe com leted if the work involved b First 20
( s secon need not R T Total No. Additional CITY Tem e Tel. No. 286_36.36
the permit is for one hundred dollars ($100)or less.)
I certifyPLAN CHECK
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'Censorion Laws. fighting Fixtures First 20 ADDRESS 1560 N. Lassen -
Additional
t Total No. CITY Ontario Tel. Nc982_7880
Dot O-` Applicant/�(�'' to Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT
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 TelNo
deemed revoked. Hood — Fan — Other— Ontario . . —
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.0-10
(commencing with Section 7000) of Division 3 of the Business DISTRICT NO. PROLE ED BY
and Professions Code, and my license is in full force and effect. Power Apparatus 8 Large Appliances `I / d
/.^�� Size &Type HP, KW, KVA, or KVAR' ,5/ Y O
License Numbery 7>f+i Lic Class `7p FINAL V
L p q Up to I Incl.
Contrac&14er/1V AF440 6to �"eC c)` Over 1 to 10 Inci. DATE I—�I. 4- VALIDATION 0
Over 10 to 50 Ind. FINAL V U
❑ 1 am exempt under Sec. Over 50 to 100 Inc. BY W
B.&P.C. for this reason Over 100 _ W
Date: Services, Swbd., MCC'& Ponelboards ►
0 -200 Amp. Under 600 V
Signature 201 - 1000 Amp. Under 600 V
❑ Over 1000 Amp, or Over 600 V
Exemption for Reg. Mainz. Elect.
SINGLE FAMILY Temp. Power Pole &Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit �2 4 09. 1 A
I 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 # 0 0 0 0 0 `I
Professions Code):
❑ I, as owner of the property, will do the work and the Misc. Conduits & Conductors 2 0 - 7.791
structure is not intended or offered for sole (Section Other (See Complete Fee Schedule)— '
7044, Business and Professions Code). 0 0 0 7.7.9 1 50
CONSTRUCTION LENDING AGENCY 0 8. 0 1 8 3
1 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 .
(Sec. 3097, Civ. C.).
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE 1 10150
Lender's Address
I certify that I have read this application and state that the TOTAL FEE ?w
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-me ioned operty for in ection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date
COUNTY OF LOS ANC'L ES TEMPLE.CITY # 0508 ELECTRICAL PERMIT:
DEPARTMENT OF PUBLZWORKS' 9701 LAS TUNAS EL 0508 9911290039
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT: -
LEGAL ID: FEES PAID BUILDING ADDRESS:
TR: 37580 LT: 4 10335 LA ROSA DR
FEE DESCRIPTION: QUANTITY: UDM: AMOUNT: TEMP CA 917803402
ASSESSOR INFORMATION NUMBER: NEAREST CROSS STREET: ARDEN
8585-018-045 - Al PERMIT ISSUANCE FEF 27-75 THOMAS PAGE: 597 GRID: B4 LOCALITY: TEMPLE CITY
_ _ G1 OUTLETS-LGT,SW,RECP 11.00 OUT 21.45
TENANT- G2 LIGHTING FIXTURES 2.00 LGT 3.90 ISSUED ON: PROCESSED LAN BY: EXPIRES ON:
TOTAL FEES 53.10 11/29/99 UT 05/27/00
___ _ _
I444^„P,INERO BALMGR E;ANA (626)L
-8108-
itS55 LA ROSH
T 9'�.i8U 5q U[ V -b S PT 1'.TN OF WORK
ELECTRICAL FOR NEW BEDROOM
APPLICANT: TEL. NO:
SAME AS OWNER
SPECIAL CONDITIONS:
PtAGELES COCl
YEL- NU: I OS y,1tP-ROVALS Du iNSPECTOR SIG
NA.T NATURE
SAME AS OWNER
^_..
i_IC. NO iTEMPORARY POWER POLE —
UNDERi;ROU1JD CONDL'1T Ji I
i;ARCHI_(E:TOR EiJGINEER: TEL. NO: / In_ccR GROUND —I
�.-_
LIC. NO: X111117 ROUGH'CCNDUIT
ROUGH WIRING
U
n n O L�� ��1nM MAIN WATER LINE
PLASTIC Y/N METAL Y/N
UTILITY COMPANY NOI IFIEC
o o :
O�
SerViiCCe That <
REPORT ID: DPR265 ROUTE TO: BS0508