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Home My Public Portal About10410 LA ROSA DR_Electrical__ WORKERS' COMPENSATION DECLARATION CE B63 ID,t3, APPLICATION FOR ELECTRICAL PERMIT I hereby affirm that I have a certificate of consent to self CE-B06G insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY or a certified copy thereof (Sec. 3800, Lab. C.J Policy No. JOB ❑ Company FOR APPLICANT TO PILL IN ADDRESS /�4/� (R�, F�t?SQ �C• /7Ql Certified copy is hereby furnished. Nev, Wags.dgs. & Pools EACH NO. FEE LOCALITY (� , Z , ❑ Certified copy is filed with the county building inspec- 1 8 2-Fomily, Sq. FL $ — $ tion department. Multi-family Sq. Ft. — NEAREST "OeAl �R• Residential Swimming Poo IS CROSS ST. Ids"" Date Applicant OWNER OR q FIRM NAME 4u�.wo 5 VENT'cLJei� CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light 7 Sw,� �nI MAQ `A Zk_• IL R,gb,� /� COMPENSATION INSURANCE First 20 Ov ADDRESS iO (This section need not be completed if the work involved by Total NoB�ILsaJ�"E Tel. No . Additional the permit is for one hundred dollars ($100)or less.) onal CIE!CHECK I certify that in the performance of the work for which this APPLICANT permit is issued, I shall not emplo y person in an manner so as to become subject to ih orke s'Compensa an laws. Lighting Fixtures First 20 Q ADDRESS Total No. Additional CITY T Date�Applicant Fixed Appliances Not Over I HP PERMIT NOTICE TO APPLICANT: If, er king this Cert icate of APPLICANT Exemption, you should come subject to the Workers' Range_ Heater_D.W. — Compensation provisions of the Labor Code, you must forth- Oven _ Dryer _ W.M.— ADDRESS with comply with such provisions or this permit shall be Top _ FAU —W.H. — deemed revoked. CITY Tel. No. LICENSED CONTRACTORS DECLARATION Hood — Fon —Other_ Dis _ Room Air Cond. Class. I hereby affirm that I am licensed under provisions of Chapter 9 p' LICENSE OR REG. NUMBER (commencing with Section 7000) of Division 3 of the Business DISTRICT NO. PROCES D BY d' and Professions Code,and my license is in full force and effect. Power Apparatus 8 Large Appliances T' 0. Size &Type HP, KW, KVA, or KVAR c U//lXl V License Number Lic. Class Up to 1 incl FINAL �� A fl: Over 1 to 10 Incl. DATE VALIDATION U' Contractor Date Over 10 to 50 Incl. FINAL W ❑ I am exempt under Sec. Over 50 to 100 Inc. BY d B.BP.C. for this reason Over loo Services, Swbd., MCC 8 Ponelboards Date: .0 - 200 Amp. Under 600 V ► # e e a e a 2 Signature 201,- 1000 Amp. Under 600 V ) e - 31.25 ❑ Exemption for Reg. Maint. Elect. Over 1000 Amp. or Over 600 V e e s 31.2 5 6 SINGLE FAMILY Temp. Power Pole 8 Appurtenances HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit 10.16-85 1 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): f JC]I 1, 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)_ , 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 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 "ave-menti / property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Aguati,,Ae of Permittee Date WORKERS'COMPENSATION DECLARATION CE-806 10/81 APPLICATION FOR ELECTRICAL PERMIT I hereby affirm that I have a certificate of consent to self CE-8066 , insure, a,a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY or a certified copy thereof (Sec. 3800, Lab. C.) Policy No. Company FOR APPLICANT TO FILL IN JOB Certified copy is hereby furnished. New Residential Bldgs, 8 Pools EACH NO. FEE ADDRESS 10410 La Rosa ❑ Certified copy is filed with the county building inspec- 18 2-Family, Sq. FL 2050 $ — $ LOCAUTYTem le Cit tion department. Multi-family Sq. Ft. — NEAREST Residential Swimming Pools CROSS ST. Arden Dote ApplicantOIRM NAMEWNER OR Fairhaiiihil CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Re<_Light_$w._ MAIL COMPENSATION INSURANCE ADDRESS 9088 Las Tunas (This section need not be completed if the work involved byFirst 20 CITY the permit is for one hundred dollars ($100)or lost.) is tai No. Additional Temple City Tel. No. 286_36.36 I certif that in the erformance of the work for which this PLAN CHECK v 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 CITY Tel. No. Doted–oZs'��gpplimnt A ' Ontario 982-7880 Fixed Appliances Not Over I HP PERMIT NOTICE TO APPLICANT: If, after making this Certificate of APPLICANiMart in Electric Exemption, you should become subject to the Workers' large— 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 Class. C-1 O (commencing with Section 7000) of Division 3 of the BusinessDISTRICT NOPROCESSED BY ` and Professions Code,and my license is in full force and effect. Power Apparatus 8 Large Appliances . p2 O /� Size 8 Type HP, KW, KVA, or K\/AR n License Number 3a'y9,22. Lic. Class a_/0 W Up to I Incl.. FINAL �' `'got, �Lrerpy �� Over 1 to 101nc1. DATE /�r � VALIDATION O 19 Contractor/" DCfd" Over 10 to 50 Incl ( V ❑ FINAL 1 am exempt under Sec. Over 50 to 100 Inc. BY `^ a B.BP.C. for this reason Over 100 Z Date: Services, Swbd., MCC 8 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 8 Appurtenances :=..7 1 6 rO A HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit I hereby affirm that I am exempt from the Contractor's License ' c o e o e 'Z Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits Professions Code): M'rsc. Conduits 8 Conductors o 0 ❑ I, as owner of the property, where the work and the Other (See Complete Fee Schedule)_ 2 '$G 25 structure is not intended or offered for sale (Section . s 7044, Business and Professions Code). � Polo, c S o.8 Z 2 5 o CONSTRUCTION LENDING AGENCY 1 1.2 CI—8i 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-Tofal) (Sec. 3097, Civ. C.). PLAN CHECKING FEE Lender's Name PERMIT ISSUING FEE 1 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 inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date