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HomeMy Public PortalAbout10415 LA ROSA DR_Electrical__ Worm that COMPENSATIONDECLARATION of corse CE 863 ID/BI APPLICATION FOR ELECTRICAL PERMIT I hereby affirm that 1 have a certificate of consent to self CEBO6G insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES �I BUILDING AND SAFETY or a certified copy thereof (Sec. 3800, Lab. C.) 116e Policy No. Company _ FOR APPLICANT TO FILL IN JOB Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE - ADDRESS 10415 La Rosa Certified copy is filed with the county building inspec- I & 2-Family, Sq. Ft, 1916 $ — $ ( 1 LOCALITY Tem le Cit tion department. Multi-family Sq. Ft. — 'NEAREST CROSS ST, Ardpn Residential Swimming Pools OWNER OR Dote Applicant FIRM NAME Fairhaven Development CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: RecLight_Sw._ MAIL COMPENSATION INSURANCE ADDRESS 9088 E. Las Tunas s section neenot be completed if the work involved b First 20 2$6-3636 (Thid P T Total No. Additional CITY Temple City Tel. No. the permit is for one hundred dollars ($100) or less.) 1 certify P N that in the performance of the work for which this PIACHECK permit is issued, shall not employ any person in any manner APPLICANT Martin Electric so as to become subject to the Workers'Compensation Laws, Lighting Fixtures First 20 ADDRESS 1560 N. Lassen '��/- 7r-y /d y`v_�� / Tocol No, Additional Dote Applicant ([lc.�K RJy CITY Ontario Tel No. 9$2-7$$0 Fixed Appliances Not Over 1 HP PERMIT NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT Mg Exemption, you should become subject to the Workers' Range_ Heater.D.W. — rtin EleCtriC Compensation provisions of the Labor Code, you must forth- Oven — Dryer — W.M.— ADDRESS 1560 N. Lassen with comply with such provisions or this permit shall be Top — FAU —W.H. — deemed revoked. - Hood Fan _Other— CITY Ontario Tel. No. 98207$$0 LICENSED CONTRACTORS DECLARATION LICENSE OR I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. REG. NUMBER 304982 Cloes.i (commencing with Section 7000) of Division 3 of the Business DISTRICT NO. PROCE ED BY and Professions Code,and my license is in full force and effect. Power Apparatus 8 large Appliances >} � c,/c]^�I A Size&Type HP, KW, KVA, or KVAR' /OQ l j� O License Numbe,30 �/ �' V.- Lic Class , FINAL V J� �i� Up to 1 Incl. Contra¢o/ ��'y " �!/Tmt U��� `+ � Over 1 to 10 1.0. DATE -84- VALIDATION O ❑ Over 10 to 50 Incl. V FINAL I am exempt under Sec. Over 50 to 100 Inc. BY ---x C 6 B.&P.C. for this reason - Over 100 W Services, 5wbd., MCC&Panelboords ► - Z Date: 0-200 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 &Appurtenances z2 4 Q$6 A HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit I hereby affirm that I am exempt from the Contractor's License # 0 0 0 0 - 2 Low for the following reason (Section 7031,5, Business and Additional Sign Branch Circuits - Professions Code): 2 0 0 77, 56 I, as owner of the property, will do the work and the Misc. Conduits & Conductors m structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ , o o a ']7,5 6� 7044, Business and Professions Code). o $O 1 _83 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) G (Sec. 3D97, Ci, C.), PLAN CHECKING FEE Lender's Name PERMIT ISSUING FEE 10 50 Lender's Address I certify that I have read this application and state that the TOTAL FEE �w S above information is correct. I agree to comply with all County - ordinances and Slate laws regulating Electrical wiring, and hereby authorize representatives of this County to enter upon the above-mentioned property for i pection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date WORKERS'COMPENSATION DECLARATION m19D�„a� APPLICATION FOR ELECTRICAL PERMIT O I herebffi f. arm that I have a certificate of consent to self [[ insure, or a certificate,of Workers' Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS or a certified copy thereof (Sec. 3800, Lab. C.) Policy No. Company FOR APPLICANT TO FILL IN JOB ff ❑Certified copy is hereby furnished. New Residential Bldgs. 8 Pools EACH NO. FEE ADDRESS I I S L-, OS LX ❑Certified co is filed with the count building inspec- 1 8 2-Fomil S Ft. $ — $ LOCALITY EWl i,E, V PY Y 9 P Y. 9. I' T 1 tion department. Multi-fomily Sq. Ft. — NEAREST (� Residential Swimming Pools - CROSS ST. Date Applicant OWNER OR II FIRMNAME,)AC1r, �' em CERTIFICATE OF EXEMPTION FROM WORKERS' �. Outlets: Rec)y' Light�Sw.L IL oo > COMPENSATION INSURANCE First 20 ADDRESS Oy/S CN/AOSA L� (This permit i need net be completed lla if the work involved by Total No.�— --Additional CITYIE WpIA. C r✓ Tel. No.4WL•Z103 the permit is For one hundred dollars ($100) or less.) °'��q certify that in the performance of the work for which this PLAN CHECK �/vvv t�APPLICANT permit is issued, I shall not employ any person in any manner hting fixtures First 20 A- so as to become subject to the Workers'Compensation Laws. LigV ADDRESS Additional Total No. CITY Tel. No. Date Applicant Fixed Appliances Not Over 1 HP PERMIT NOTICE APPLICANT: If, after making this Certificate of APPLICATION Exemption,n, 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 with comply with such provisions or this permit shall be Top — FAU —W.H. — deemed revoked. Hood — Fan _Other_ CITY Tel. No. LICENSED CONTRACTORS DECLARATION LICENSE OR I hereby affirm that I am licensed under provisions of Chapter 9 Disp. Room Air Cond. L REG. NUMBER Class. (commencing with Section 7000)of Division 3 of the Business Power Apparatus 8 Large Appliances DISTRICT NO. P SSED BY Y and Professions Code,and my license is in full force and effect. CO� 0- Size 8 Type HP, KW, KVA, or KVAR O License Number Lic. Class Up to I Incl. FINAL U . Over I to 10 Incl. DATE -- VALIDATIONS DC Contractor Date❑ Over 10 to 50 Incl. FINAL F_ 1 am exempt under Sec. Over 50 to 100 Inc. BY C) O 100 Ul B.BP.C. for this reason Over CL Date: Services, Swbd., MCC 8 Panelboords , Z 0- 200 Amp. Under 600 V Signature 201 - 1000 Amp. Under 600 V ❑ Exemption for Reg. Mainz. Elect. Over 1000 Amp. or Over 600 V ;�0 7 a 2'A SINGLE FAMILY # e •e •to e Temp. with One Branch Circuit mp. Power Pole 8 Appurtenances HOME OWNER-BUILDER DECLARATION •� i e hereby affirm that I exempt from the Contractor's License Si Law for the followingg r reason (Section 7031 5, Business and Additional Sign Branch Circuits o 9.22-88 , . Professions Code): ❑ I, as owner of the property, will do the work and the Misc. Conduits 8 Conductors structure is not intended or offered for sole(Section 7044, Other (See Complete Fee Schedule)_ , 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 r esentatives of this County to enter upon the above-mPrt'o a property for inspection purposes. <1 -LZ–)? SEE$EE REVERSE FOR EXPLANATORY LANGUAGE Ugnature of Permittee Date y ©'