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Home My Public Portal About10440 LA ROSA DR_Electrical__ WORKERS COMPENSATION DECLARATION 76A663 10i61 APPLICATION FOR ELECTRICAL PERMIT I hereby.a�lrm that I have o certificate of consent to self CE-BD6G insure, ocertificate 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 �q q Certified copy is hereby furnished. New Residential Bldgs. 8 Pools EACH NO. FEE ADDRESS L/L F 4Cf 4A Q Certified copy is filed with the county building inspec- 18 2-Family, Sq. Ft. $ — $ LOCALITY ENf/�LC C tion department. Multi-family Sq. Ft. — NEAREST Residential Swimming CROSS CROSS ST. mm Date Applicant ` - - _ . OFIRWNER NAOR M ME CERTIFICATE OF EXEMPTION FROM WORKERS' , MAIL / O / qO�� Outlets: RecLight Sw_ G� ['C COMPENSATION INSURANCE First 20_ ADDRESS OLI 44 (This section need not he completed if the work involvod by Total No. CITY Tel. No. the permit is for one hundred'dollars ($100)or less.) Additional j% L.[ e. ' \ 4 j. certify that in the performancethe work for which this permit is issued, shall nott employ any PLAN CHECK oy any person in ny manner APPLICANT so as to become subject to the Wor n'Compe a ' n Laws. Lighting Fixtures First 20 ADDRESS Total No. J 7 Additional CITY Tel. No. Date Applicant Fixed Appliances Not Over 1 HP PERMIT NOTIC TO APPLICANT: If, after making this Certificate o 1 APPLICANTExemption, you should become subject to the Wo ers' Range_ Heater—D.W.W. ` Compensation provisions of the Labor Code, you must - 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 1bDisp. Room Air Card. LICENSE OR .s I hereby affirm that I am licensed under provisions of Chapter 9 REG. NUMBER Class. } (commencing with Section 70) of Division 3 of the Business Power Apparatus 8 Large Appliances DISTRICT NO. ^ P SSED BY d' and Professions Code,and my license is in full force and effect. U V Size 8 Type HP, KW, KVA, or KVAR License Number Lic. Class Up to 1 Incl. FINAL Contractor Date Over 1 to 10 Incl. DATE VALIDATION U ❑ Over 10 to 50 Incl. FIN W am exempt under Sec. Over 50 to 100 Inc. BV d Over 100 B.BP.C. for this reason Z_ Date: Services, Swbd., MCC 8 Panelboards 0 -200 Amp. Under 600 V Signature 201 - 1000 Amp. Under 600 V ❑ Exemption for Reg. Maint. Elect. Over 1000 Amp. or Over 600 V SINGLE FAMILY Temp. Power Pole 8 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): 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)_ , 2 5 7 6 4 A 7044, Business and Professions Code). # •,• • •:• 2 CONSTRUCTION LENDING AGENCY 1 hereby affirm that there is a construction lending agency for it e e 1 7.25 the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) (Sec. 3097, Civ. C.). e e e 1 7.256 PLAN CHECKING FEE Lender's Name IQ27.Y86 PERMIT ISSUING FEE �0 Lender's Address I certify that I have read this application and state thattheTOTAL FEE - above information is correct. I agree to comply with all County ordinances and State laws regulating Electrical wiring, and hereby au thoriz�repsentatives of this County to enter upon above-me iia Yproplanv to spection purposes./A_ SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee G Dal �Y DEC TION WORKERS'that t I have a certificate cafe of corse CE 867 10/81 APPLICATION FOR ELECTRICAL PERMIT I hereby affirm that 1 have a certificate of consent to self CE806G insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES'TPro 376-eQ BUILDING AND SAFETY 07' /,2- 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 10440 La Rosa ❑ Certified copy is filed with the county building inspec- 1 & 2-Family, Sq. Ft. 1644 $ — $ 2 LOCALITY Temple City tion department. Multi-family Sq. Ft. — 'NEAREST Residential Swimming Pools CROSS OWNER T. Arden Date Applicant FIRM NAME Fairhaven Development CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: RecLight_Sw._ 'MAIL COMPENSATION INSURANCE First 20 ADDRESS 9088 Las Tunas (This section need not be completed if the work Involved by Total No. Additional CITY Temple Cit Tel. No.286-3636 the permit is for one hundred dollars ($100)or less.) PLAN CHECK I certify that in the performance of the work for which this APPLICANT Martin Electric permit is issued, I shall not employ any person in any manner so as to become subject to theWerk-rs' pe anon L Lighting Fixtures First 20 ADDRESS 1560 N. Lassen �� Additional Total No. CITY Ontario Tel. No. 982-7880 Date//~�o ✓�3 Applicant ��7�� /'e7 PI Fixed Appliances Not Over t HP PERMIT NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT Martin 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.[. CITY Tel. No. deemed revoked. Ontario 982-7880 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 DISTRICT N0. PROCESSED BY and Professions Code,and m license is in full force and effect. - Power Apparatus 8 Large Appliances Y y Size & Type HP, KW, KVA, or KVAR' O z U License Number. g(5T ?6_X Lic C/Class _10 Up to 1 Incl. FINAL h U Over 1 to 10 Incl. DATE J��Z��j VALIDATION, 2 O r/'/�' Over 10 to 50 Incl. Contractor Date ❑ f— FINAL 7626 'W am exempt under Sec. Over 50 to 100 Inc. BY 2 1L B.&P.C. for this reason Over 100 •e e a 7 6 26•.�M 2 D te: Services, Swbd., MCC & Panelboards 0 -200 Amp. Under 600 V (�f ` G� 11.) 8+-8 3 Signature 201 - 1000 Amp. Under 600 V ❑ Over ID00 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): ❑ 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 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 property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE - / Signature of Permittee Date ,