HomeMy Public PortalAbout10405 LA ROSA DR_Electrical__ WORKERS' COMPENSATION DECLARATION CE-806 ID,B, APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm That I have a certificate of consent to self CE-806G �
insure, ar a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES / e� BUILDING AND SAFETY
or a certified copy thereof (Sec. 3800, Lob. C.)
Policy No. Company FOR APPLICANT TO FILL IN JOB
Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO, FEE ADDRESS 10405 La Rosa
❑ I & 2-Family, LOCALITY
Certified copy is filed with the county building ihspec- y, Sq. Ft. 1 926 $ — $ Temple Olt
tion department. 'Multi-family Sq. Ft. — NEAREST Arden
Residential Swimming Pools CROSS ST.
Date Applicant OWNER OR
FIRM NAME Fairhaven Development
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: RecLight_Sw. ''MAIL
COMPENSATION INSURANCE ADDRESS 9088 E. LBS Tunas
t be com leted'if the work involved by
First 20
Is secon neenoP Additional CITY Temple Olt Tel. No. 286-3636
the permit is for one hundred dollars ($100) or less.) Total No.
that in the performance of the work for which this PLAN CHECK
I certify P APPLICANTMartin Electriir
permit is issued, 1 shop 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
'7 Total No. Additional
Dote?ZL-9-- A bcan✓ CITY Ontario Tel. No. 982_7880
PP / Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT -Martln 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 f 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. PROCESS BY
and Professions Code,and m license is in full force and effect. Power Apparatus 8 Large Appliances �/ Y
��s y 0.
Size&Type HP, KW, KVA, or KVAR' Si f)/ O
License Number`���U Lic Class Up FINAL V
/y Up to 1 Incl.
Contrafio}1Ar'%!iL/ � &_& Jtr. 7^1-47` Over 1 to 101nc1., DATE �s���, VALIDATION O
Over 10 to 50 Incl. FINAL ~
❑ am exempt under Sec. Over 50 to 100 Inc. BY �Q r
B.&P.C. for this reason Over 100
In
Date:
Services, Swbd., MCC & Panelboards , ?
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
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 '
Professions Code): ;94087A
❑ 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)— , # 0 0 o e - 2
7044, Business and Professions Code). 2 e - 7791
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for o o - 77.916
the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) '1 Ej/r
(Sec. 3097, Civ. C.). 0801 —83
PLAN CHECKING FEE
Leader's Name
PERMIT ISSUING FEE 1 SO
Lender's Address �j
I certify that I have read this application and state that the TOTAL FEE / 9�
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
1 -YK 1-a9-�3
Signature of Permittee Date '