HomeMy Public PortalAbout4829 AGNES AVE_Electrical_7/10/1980_ WORKERS'COMPENSATION DECLARATION CE 806G (2 80►'63 APPLICATION FOR ELECTRICAL -PERMIT
CE 8
I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES' . BUILDING AND SAFETY °
insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec 3800,Lab C)
Policy No 550115 Company STATE COMPENSATION FOR APPLICANT TO FILL IN
JOB
QTS FUND New Residential Bldgs &Pools EACH NO e FEE ADDRESS 482 A B C D E AGNES �.
a Cerrtified copy is hereby,furnished 1 &2 Family,Sq Ft N '$ — $ LOCALITY
*
Multifamily Sq Ft 7000 • — • NEAREST '
Certified copy is filed with the county,building inspection P CROSS ST Q Z..iz�
departmOWN EfR
ent Residential Swimming Pools 1
JERRY'S ELECTRIC INC f
FIRM
OR GEORGE WIEG '
t - FIRM NAME e
'
Dated-10-80' Applicant f Outlets Rec—Light SwMSAIL r
' .t First 20 �¢ ADDRESS 1425 MELANIE LANE.
CERTIFICATE OF EXEMPTION FROM WORKERS' Total No Additional CITY- ARCADIA " Tel No 445 2803
T, COMPENSATION INSURANCE, PLAN CHECK a
1 O
` �'° � � ' APPLICANT,, -
(This section need not be completed if the work involved Lighting Fixtures" First 20 ADDRESS V
by the permit its for one hundred dollds ($100) or less) fr
' I Total{No Additional O
I certify that in the performance of the work+for which this Fixed Appliances Not Over 1 HP ) • CITY ` Tel No
permit,is issued, I shall not employ any person to any manner . PERMIT 15
so as to become subject`to the Workers' Compensation,Laws Range_ Heater D W _° , APPLICANT , JERRY'S ELECTRIC INC., IL
LU
,dOven _ Dryer_W M va
ADDRESS BOX 159 i �' Z'
' t, p _ _ToFAU W H._
Date F Applicant v i CITY �W PARK TelIVo 62 188
Hood — Fan —Other
NOTICE TO APPLICANT If, after making this Certificate of Disp Room Air Cond_ LICENSE OR
Exemption, you should become subject to thet�`Workers' s • REG NUMBER C-1025947%lass C-10-
Compensation provisions of the- abor Code, you must forth Power Apparatus& Large Appliances y DISTRICT NO PROCES D SYT'
with comply with such provisions or this permit shall be
deemed revoked r Size&Type HP,KW,KVA or ICVAR
c Up to 1 Incl
' • Over 1 to 10 Incl_ - DATE_
°
LICENSED CONTRACTORS DECLARATION i Over 10 to 50 Incl /'��: �� VALIDATION
I hereby affirm that I am licensed under provisions of Chapter .0 Over 50 to 100 Inc i FINAL
9 (commencing with Section 7000 of Division 3 of the Busi BY
( g ) Over 100 ++
nese and Professions Code, and my license is in full force and 5
effect ,
Services
License Number G-102594 is Class C-1 Q 0 200 Amp"Under 600 V , -• '�e� `�
201 1000 Amp Under 600 V•
Contractor•TRRRYt S ETMTRrW, INC, 7-10-80 Over11000•Amp or Over 600 V
2,
HOME
�p ,
• I
HOME OWNER-BUILDER DECLARATION ' k Temp Power Pole&Appurtenances ' ,
Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's Additional Sigri Branch Circuits @ 1 2 9,7-A -
License Law for the following reason (Section 7031 5, ors -
ness and Professions Code) �' # o 'o a Cr o 2
' Mist Conduits&Conductors ' ' i
I, as owner of the property, will do the work and the Other(See Complete Fee Schedule)— " r'z , T,° 1 47.00
structure is not intended or offered for sale (Section 5 +
7044,Business and Professions Code) - ) a a 1 4 7"0 0
`
CONST RUCTION,LENDING AGENCY ", , ,
I hereby affirm that there is a construction lending agency 4 0-7 1 6-60
"� f
for the performance of the work for which this permit is PERMIT FEE •`` r y (Sub-Total►_ •1[}Q• Q -i
issued(Sec 3097,Civ C) `
Lender's Name PLAN CHECKING FEE (One Fourth Permit Fee)
Lender's Address PERMIT ISSUING FEE i f -7-30 ,
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 uthorize representa es of this County to enter upon
th ab a mentioned rope for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee _t ate