HomeMy Public PortalAbout10355 LA ROSA DR_Electrical__ DEC
TION
76A66
WORKERS't I have
a certificate
cafe of corse CE-806 10,01 APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have o certificate of consent to self CE-0066 '
insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified copy thereof (Sec. 3000, Lob. C.)
Policy No. Company FOR APPLICANT TO FILL IN JOB
Certified co is hereby furnished. EACH NO. FEE ADDRESS 1355 La Rosa
PY Y New Residential Bldgs. 8 Pools
—
Certified copy is filed with the county building inspec- 18 2-Family, Sq. Ft. 1644 $ $ 67 LOCALITY Temple City
tion department. Multi-family Sq. Ft. — 'NEAREST
CROSS ST. Arden
Residential Swimming Pools OWNER OR
Date Applicant FIRM NAME Fairhaven
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec_Light_Sw._ MAIL 9088 Las Tunas
COMPENSATION INSURANCE First 20 ADDRESS
(This section need not be completed if the work involved by Total No. CITY Tel. No.
the permit is for one hundred dollars ($100) or less.) Additional TempleCity
certify that in the performance of the work for which this PLAN CHECKAPPLICANT Martin Electric
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. ighting Fixtures First 20 ADDRESS 1560 N. Lassen
Total No. Additional 982-7880
y� CITY Ontario Tel. No.
Datez- �Applicont/,' ixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT Martin Elec 'c
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. qS2_7SS()
LICENSED CONTRACTORS DECLARATION LICENSE OR
I hereby off irm that I am licensed under provisions of Chapter 9 Disp. Room Air Cond. REG. NUMBER 304982 Class.("-
10
(commencing with Section 7000) of Division 3 of the Business DISTRICT NO. PROCES ED BY
and Professions Code,and my
license is in full force and effect. Power Apparatus 8 Large Appliances (� Y
!( CL
Size 8 Type HP, KW, KVA, or KVARS/UO Q
License Number.��7 /�•�. Lic Cl... Up to I Incl. FINAL �� V
z •�/�j/O' Over I to 10 Ind. DATE /--��O VALIDATION Q
Contractor&16! 'f/� �. bate �-a 9.�Ea❑ Over 10 to 50 Incl. FINAL L&I
I am exempt under Sec. Over 50 to 100 Inc. BV --�• F-a.p,�r,�s IL
B.BP.C. for this reason Over 100 W
Dote: Services, Swbd., MCC 8 Ponelboards PON.
- 200 Amp. Under 600 V
Signature 201 - 1000 Amp. Under 600 V
❑ Exemption for Reg. Mainz. Elect. Over 1000 Amp. or Over 600 V
SINGLE FAMILY Temp. Power Pole 8 Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License 40 a9 A
Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits
Professions Code): o 0 o e o2
❑ 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)— ► 2 0 - 779 1
7044, Business and Professions Code). e o 0 77. 9 )
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for 0 8 0 1 -83
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
Lender's Address I�/
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-menu ne/d�/rplroperty for/in//sp/gcrion purposes. �C-7 SEE REVERSE FOR EXPLANATORY LANGUAGE
K LC.tir �� j 7-12
Signature of Permittee 7
Date