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Home My Public Portal About10420 LA ROSA DR_Electrical__ WORKERS' COMPENSATION DECLARATION 76A663CE-806 ID/SI 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 / BUILDING AND SAFETY or o certified copy thereof (Sec. 3800, Lab. C.) - t/ Policy No. Company FOR APPLICANT TO FILL IN JOB ADDRESS 1O4ZO La Rosa Certified copy is hereby furnished. New Residential Bldgs. 8 Pools EACH NO. FEE ❑ Certified copy is filed with the county building inspec- 18 2-Family, Sq. Ft. 1926 $ — $ 6 7LOCALITY Temple City - tion department. Multi-family Sq. Ft. NEARESTCROSS ST. Arden Residential Swimming Pools OWNER OR Date Applicant FIRM NAME Fairhaven Demplopment CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec_Light_Sw._ 'MAIL COMPENSATION INSURANCE I ADDRESS 9088 Las Tunas (This section need not be completed if the work involved by First 20 Total No. Additional CITY Temple Cit Tel. No.286-3636 the permit is for one hundred dollars ($100)or less.) I certif that in the erformance of the work for which this PLAN CHECK Y 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 Datell—�- Applicant CITY Ontario Tel, No.982-7880 NOTICE TO APPLICANT: If, after makiri this Certificate of Fixed Appliances Not Over 1 HE PERMIT B e_ Heater—D.W. — APPLICANT Martin Electric Exemption, you should become subject t6 the Workers' Ran 9 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 Ontario Tel. deemed revoked. - Hood _ Fan _Other— 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-10 (commencing with Section 7000) of Division 3 of the Business Power Apparatus 8 Large Appliances y - DISTRICT NO. PROCESSED BY and Professions Code,and my license is in full force and effect. Size 8 Type HP, KW, KVA, or KVAR- /j O License Number 351� Lic. Class —10 Up to 1 Ind. FINAL V M14Q 1 2� j7LC<'62)(f Z' ��b• Over I to 10 Incl. DATE d- �' - VALIDATION Q Contractor Date❑ Over 10 to 50 Incl. FINAL am exempt under Sec. Over 50 to 100 Inc. BY 1 B.BP.C. for this reason Over I00 Us Date: Services, Swbd., MCC 8 Panelboards oil, - 0 - 200 Amp. Under 600 V Signature 201 - 1000 Amp. Under 600 V ' ❑ Exemption for Reg. Mai _ Over 1000 Amp. or Over 600Maim. Elect. rr SINGLE FAMILY Temp. Power Pole 8 Appurtenances 1+n a 1 6`6 d HOME OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Sign with One Branch Circuit 2•o 0 7.7 9 ) Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits Professions Code): o-o 077.9*1 '` ❑ I, as owner of theP P yert ro will do the work and the Misc. Conduits 8 Conductors Other See Complete Fee Schedule)- 7044, chedule I )'12 9- 3 structure is not intended or offered for sale (Section ( P )— 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 10 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 insp tion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of of Permittees Date WORKERS'COMPENSATION DECLARATION 76A663 ,d,e, APPLICATION FOR ELECTRICAL PERMIT {� I hoaby affirm that I have a certificate of consent to self insure, CE806G uor A certificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY Copy thereos(S3800,Lab.C.) Policy No. G Company FOR APPLICANT TO FILL IN JOB j/,[�'^ /- !J✓ /) ❑ Certified copy is hereby furnished. EACH NO. FEE -ADDRESS New Residential Bldgs. & Pools •;�� Certified copy is filed with the county building inspection 1 & 2-Family,Sq.Ft. '� $ _ $ LOCALITY �' department. Multi-Family Sq.Ft NEAREST Q� �lCROSS ST. Date 1 —Applicant Residential Swimming Pools OWNER OR FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec 4 Light z Sw.3 MAIL COMPENSATION INSURANCE First 20 / D ADDRESS (This section need not be completed if the work involved by the CITY Tel.No. permit is for one hundred dollars ($100) or less.) iota!No. Additional I certify that in the performance of the work for which this permit PLAN CHECK /' O� APPLICANT 6J is issued, I shall not employ any person in any manner so as to became subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS q; Additional / o o Total No. CITY ��J�Oe rel.No.O// Date Applicant Fixed Appliances Not Over 1 HP NOTICE TO APPLICANT: If, after making this Certificate of PERMIT Exemption,you should become subject to the WorkersCompensation Range_ Heater_ DW _ APPLICANT provisions of the Labor Code, you must forthwith comply with such Oven _ Dryer _ W.M._ ADDRESS provisions or this permit shall be deemed revoked. Top — FAU W.H. LICENSED CONTRACTORS DECLARATION Hood — Fan Other_ V Ll CITY Tel.No. I hereby affirm that I am licensed under provisions of Chapter 9LCENSE OR / �//�,,. (commencing with Section 7000) of Division 3 of the Business and Disp. — Room Air Cond. REG.NUMBER) S/rs Gass. dL� Professions Code,and my license is in full force and effect. DISTRICT NO. P OC SED By Power Apparatus& Large Appliances 5�55�ksBsf C-3� Size& Type HP, KW,KVA, or KVAR License Number Lia Class Up to 1 Incl. FINAL _ U v/Y _ Over 1 to 10 Incl. DATE —�_v) �� VALIDATION Contractor ate 2 —�/ .Over 10 to 50 Incl. U ❑ FINAL —I _ U am exempt under Sec. Over 50 to 100 Inc. BV !V/' W"�' W B&P.C. for this reason Over 100 d cn Services, Swbd.,MCC& Paoelboards ® Z Date: 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 Pale& Appurtenances HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit . . y I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits Code): :33t('1 175'.1'171 ❑ rf as owner of the property,will do the work Misc.Conduits&Conductors k and the structure i 1_- f��7 is not intended or offered for sale (Section 7044, Business Other (See Complete Fee Schedule) and Professions Code). TOTAL 29 - 70 CONSTRUCTION LENDING AGENCY CHE!l ;?y„i l I hereby affirm that there is a construction lending agency for the O CHANGE ,`I:! performance of the work for which this permit is issued(Sec.3097, PERMIT FEE (Sub-Total) Civ. C.). PLAN CHECKING FEE 1 'u1 Lender's Name 111300-000 �,ff1!; a PERMIT ISSUING FEE F- Lender's 1 pfl t*i certify Ls Address I certify that I have read this appiica[ion and state that the above TOTAL FEE 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 propert for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date