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HomeMy Public PortalAbout10430 LA ROSA DR_Electrical__ WORKERS' COMPENSATION DECLARATION CE-806G ID,B, APPLICATION FOR ELECTRICAL PERMIT I hereby affirm that I have a certificate of consent to self G insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY or a certified copy thereof (Sec. 3800, Lab. C.) Policy No✓�ompany lerw sC er gx FOR APPLICANT TO FILL IN JOB Certified'Copy is hereby furnished. New Residential Bldgs. 8 Pools EACH NO. FEE ADDRESS /%LJ �/q Ue ❑ 1 8 2-Family, LOCALITY Certified copy is filed with the c my building inspec- y. Sq. FL $ — $ P 2 C tion department. Multi-family Sq. Ft. — 'NEAREST ��xx dentiol Swimming Pools CROSS SL Date O~ Applicant �_ OWNER M ` L- e FIRM NAME / CERTIFICATE OF EXEMPTION FROM WORKERS' �— � MAIL COMPENSATION INSURANCE Outlets: Re_ _.y�__w._ ADDRESS This section need not be completed if the work involved b First 20 ' ( P Y Total No. Additional CITY Tel. No. the permit is for one hundred dollars ($100)or less.) I certify that in the performance of the work for which this APPLICANT CHECK ICANT 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 Additional Total No. CITY Tel. No. Date Applicant Fixed Appliances Not Over 1HP PERMIT NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT 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 a with comply with such provisions or this permit shall be Top. — FAU —W.H. CITY � T.I. N deemed revoked. Hood Fon _ Other_ LICENSED CONTRACTORS DECLARATION LICENSE OR I hereby offirm that I am licensed under provisions of Chapter 9 Disp. Room Air Cond. REG. NUMBER Class.e/0 (commencing with Section 7000) of Division 3 of the Business DISTRICT NO. PROCESSED BY and Professions Code, and my license is in full force and effect. Power Apparatus 8 Large Appliances /�y� d ,.. ��ry Size 8 Type HP, KW, KVA, or KVAR' Jr� ©& E_4§ F O License Numb ✓ Lic. Class r•/o Up to 1 Incl. FINAL Q V �COatfaCtO Date` Over 1 to 10 Incl. fFfNAL TE sJQ- VALIDATION O ❑ Over 70 to 50 Ind. / V am exempt under Sec. Over 50 to 100 Inc. Is. B.BP.C. for this reason Over 100 Z Dotes= � Sces p elboards y 200A Ude 600 V S'gnm rAmp. Under 600 V ❑ Exemption for Reg. MaiOver 1000 Amp. or Over 600 V nz Elect. SINGLE FAMILY Temp. Power Pole 8 Appurtenances HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit �3`7 2 1.4 A hereby affirm that I am exempt from the Contractor's License additional Sign Branch Circuits hi o o e ° Law for the following reason (Section 7031.5, Business and 'O 2 Professions Code): ElI, as owner of the property, will do the work and the Misc. Conduits 8 Conductors 12 °-° 2.5 50 structure is not intended or offered for sole (Section Other (See Complete Fee Schedule)_ ► oro 02550&' . 7044, Business and Professions Code). - CONSTRUCTION LENDING AGENCY 1 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 Ath� ve-mentoned property for spection purposes. SEE REVERSE FOREXPLANATORY LANGUAGE re of Permittee Date WORKERS' COMPENSATION DECLARATION CE-806 ,oiBl APPLICATION FOR ELECTRICAL PERMIT I hereby affirm that I have a certificate of consent to self CE-806G /` insure, ar o 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. & Pools EACH NO. FEE ADDRESS 10430 La Rosa ❑ Certified copy is filed with the county building inspec- 1 & 2-Family, Sq. Ft. 1916 $ — $ 67 06 LOCALITY Temple Cit tion department. Multi-family Sq. Ft. — 'NEAREST CROSS ST. Arden Residential Swimming Pools Date Applicant OWNER OR FIRM NAME Fairhaven Development CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec_LightSw._ '' SAIL COMPENSATION INSURANCE ADDRESS 9088 Las Tunas s section neenot completed if the work involved b First 20 (Thitid t bc p Y Total No. Additional CITY Temple Cit Tel. No. 286-3636 the permit is for one hundred dollars ($100)or less.) that in the performance of the work far which this PLAN CHECK I certify P APPLICANT Martin Electric perm it.is issued, I shall not employ any person in any manner 'so as to become subject to the Workers'Compensation Laws. Igniting Fixtures First 20 ADDRESS 1560 N. Lassen Total No. Additional Date 3 Applicant CITY Tel. No. //-o2S�-kOntario 982-7880 Fixed Appliances Not Over 1 HP PERMIT NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT Mart-in FleCtriC 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. Ontario No.982-7880 deemed revoked. CITY Tel. LICENSED CONTRACTORS DECLARATION Hood _ Fan _Other_ Disp. —. Room Air Cond. LICENSE Class. I hereby affirm that I am licensed under provisions of Chapter 9 REG. NUMBER 304982 C-IO (commencing with Section 7000) of Division 3 of the Business DISTRICT NO. PROCESSED BY and Professions Code, and m license is in full force and effect. Power Apparatus 8 Large Appliances /, Q� Y nr�^� nY Size &Type HP, KW, KVA, or KVAR' `�/ r/ Djr O License Number-90 yQ�� Lic. Class �i V z/ oo nn Up to I incl. FINAL / �p Cantra<to�,059 Y/.Lt !Gl't% pdt 7'/ ^ir Over 1 to 10 Incl. DATE {+. �(�.-/t'� _ VALIDATION O Over 10 to 50 Incl. FINAL i///��� arw (Fj ❑ I am exempt under Sec. Over 50 to 100 Inc. BY B,&P.C. for this reason Over 100 Z Date: Services, Swbd., MCC & Ponelboards 1101.0 - 200 Amp. Under 600 V Signature201 - 1000 Amp. Under 600 V ❑ Over 1000 Amp. or Over 600 V �,],1 ,6,8 A Exemption for Reg. Mainz. Elect 0 0 SINGLE FAMILY Temp. Power Pole& Appurtenances 0 'z HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit 2'0 0.77.516 1 hereby affirm that I am exempt from the Contractor's License t Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits o e o '7 7,5 6'-QProfessions Code): . . • . f ❑ I, as owner of the property, will do the work andtheMisc. Conduits& Conductors I 1,29 -83 structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ , 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY 1 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 ail County ordinances and State laws regulating Electrical wiring, and hereby authorize representatives of this County to enter upon tthh�ela�bfove-menttlneed property for insp�ton purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Dote