HomeMy Public PortalAbout4827 AGNES AVE_Electrical_7/10/1980_ WORKERS'COMPENSATION DECLARATION CE 8 6G (2 80) APPLICATION FOR ELECTRICAL PERMIT -
I hereby,affirm that I have a certificate of consent to self COUNTY OF LOS ANGELESBUILDING AND SAFETY
insure, or a certificate of Workers'Compensation Insurance,or 7-, 1
a certified copy thereof(Sec 3800,Lab C)
STATE CON FOR APPLICANT TO FILL'IN JOB Policy No011�Company OMPENSATI - EACH NO FEE ADDRESS 482 AVBI('+sDt AGNES
'�j� New Residential Bldgs &Pools
Certified copy is hereby furnishe3- S. FUND 1 &2 Family,Sq Ft $ — $ LOCAOTY , M�T CITY
y g P
Multifamily Sq Ft -E+C1(� • — . NEAREST
Certified co
department PY Bled with the count building inspection ResidentialSwimmingPools CROSS ST
P I WNER OR
FO RM NAME GEORGE WIEGAND
Date 7-1 n-SC♦ ApplicantrERRW S ETT ECTRIC a INC. Outlets Rec_Light Sw MAIL
-
First 20 ADDRESS 14 LANE
CERTIFICATE OF EXEMPTION FROM WORKERS' Total No Additional CITY ARCADIA 1 Tel
COMPENSATION INSURANCE }
- PLAN CHECK d
(This section need not be completed if the work involved APPLICANT S U
by the permit is for one hundred dollars ($100) or less) Lighting Fixtures First 20TotalAdditional - CCI certify that in the performance of the work for which this Total No CITY i Tel No
Fixed Appliances Not Over 1 HP
P employ an
permit is issued, I shall not em to PERMIT V
Y person in any manner
so as to become subject to the Workers'Compensation Laws Range—' r HeateDW APPLICANT JERRYt S ELECTRIC, INC. w
CL
Oven _ Dryer_W M ADDRESS Z
Date Applicant Top _ FAU _W H CITY $ALDWIBox 159 PARK Tel No 962 8188
Hood _ Fan —Other_
NOTICE TO APPLICANT If, after makin this Certificate of LICENSE OR C-10
Exemption, j 8 Disp._Room Air Cond
p you, should become subject to the Workers' REG NUMBE Class
Compensation provisions of the Labor Code, you must forth Power Apparatus& Large Appliances DISTRICT NO PROCES D B%
with comply with such provisions or this peririit shall be Size&TP
Type H ,KW,KVA,or KVAR nn
deemed revoked
Up to 1 Incl
Over 1 to 10 Incl FINAL
LICENSED CONTRACTORS DECLARATION - DATE l ^��_ / VALIDATION
Over 10 to 50 Incl
I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc FINA
9 (commencing with Section 7000)of Division 3 of the Bust _ -
Over 100 BY `
ness and Professions Code, and my license is-in full force and ,
effect Services
License Number C-10259475L,c Class C-10 - 0 200 Amp Under 600 V
201 1000 Amp Under 600 V
Contractor JERRY'S ELECTRIQ, INC. 7-10-80 Over 1000 Amp or Over 600 V
HOME OWNER BUILDER DECLARATION Temp Power+Pole&Appurtenances _ 1 2 9 6 A
Sign with One Branch Circuit # o°o o` o 0 2
I hereby affirm that I am exempt from the Contractor's Additional Sign Branch Circuits `
License Law for the following reason (Section 7031 5, Bust
ness and Professions Code) 2 ° 1 1900
Misc Conduits&Conductors
❑ I, as owner of the property, will do the work and the Other(See Complete Fee Schedule)— iO ° 1 19,Q 0 C5
structure is not intended or offered for sale (Section
7044, Business and Professions Code) 07. 1 6-80
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(Sec 3097 Civ C) PERMIT FEE _ (Sub-Total) 1122.00
Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee)
Lender's Address PERMIT ISSUING FEE 7600
I certify that I have read this application and state that the TOTAL FEE 119.00
above information is correct I agree to comply with all County
ordinances and State laws regulating Electrical wiring, and
hereby au orize represen es of this County to enter upon
the ab v mentioned pr ert for`inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE t
,
Signature of Permittee Date i