HomeMy Public PortalAbout4831AGNES AVE_Electrical WORKERS COMPENSATION DECLARATION `
CE 806G (2 80) APPLICATION FOR ELECTRICAL PERMIT
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 N S 4 3
INS. FUND New Residential Bidgs &Pools EACH NO FEE ADORES 8 1 A & B AGNES
o Certified copy is hereby furnished 1 &2 Family Scl Ft 2+400 $ .075 — $ LOCALITY TEMPLE CITY
Multi family Scl Ft NEAREST
Certified copy is filed with the county budding inspection CROSS ST
department ` Residential Swimming Pools OWNER OR
' FIRM NAME GORGE WIEG D
Date Applicant Outlets Rec_Light First 20 MAIL
ADDRESS 1425 MELANIE LANE
CERTIFICATE OF EXEMPTION FROM'WORKERS Total No Additional CITY ARCADIA Tel No 445 2803 }
' COMPENSATION INSURANCE PLAN CHECK 9-
(This section need not be completed if the work mvolved APPLICANT V
by the permit is for one hundred dollars ($100) or less) Lighting Fixtures First 20 ADDRESS
Total No Additional
I certify that in the performance of the work for which thisN1 HP CITY Tel No 0
Fixed Appliances Not Over
permit is issued I shall not employ any person in any manner PERMIT V
so as to become subject to the Workers Compensation Laws Range_Heater D W APPLICANT JERRY'S ELECTRIC INC. Ow.
Oven _ Dryer_W M ADDRESS ROX 159 M( , Z
Date Applicant Top _ FAU _W H _
Hood — Fan _Other_ CITYBALDWIN PARK HI 7 YeI No 962 9188
NOTICE TO APPLICANT If after making this Certificate of Disp _ Room Air Cond_ LICENSE OR
REG NUMBERC-1025947 C-10
Exemption you should become subject to the Workers lass
Compensation provisions of the Labor Code you must forth Power Apparatus& Large Appliances DISTRICT NO PROCE SED BY
with comply with such provisions or this permit shall be /
deemed revoked Size&Type HP KW KVA or KVAR ���
Up to 1 Incl
Over 1 to 10 Incl F PIN DATE—AL
AEL 7 �1
LICENSED CONTRACTORS DECLARATION Over 10 to 50 Incl _2/��/ VALIDATION
I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc FINAL
9 (commencing with Section 7000)of Division 3 of the Busi Over 100 BY
ness and Professions Code and my license is in full force and i
effect P Services / "` •
License NumberC-10259475 Lic Class� C-10 0 200 Amp Under 600 V
201 1000 Amp Under 0 V r
Contractor)L+RRY'S ELECT�(�', INC , 7-10-80 Over 1000 Amp or Over
600 V V
HOME OWNER BUILDER DECLARATION Temp Power Pole&Appurtenances ' a
I hereby affirm that I am exempt from,the Contractor s Sign with One Branch Circuit
License Law for the following reason (Section 7031 5 Busi Additional Sign Branch Circuits
ness and Professidhs Code) S 1 2 a 8 R
Misc Conduits&Conductors ,
El I as owner of the property will do the work and the - Other(See Complete Fee Schedule)— # o • • • e 2
structure is not intended or offered for sale (Section -
7044 Business and Professions Code) 2 s s• 6700
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency - ` o e o 6 7 0 0 C
for the performance of the work for which-this permit is PERMIT FEE (Sub Total)
issued (Sec 3097 Civ C) i -6 07-1 6-80
Lender s Name PLAN CHECKING FEE (One Fourth Permit Fee) r
Lender s Address PERMIT ISSUING FEE
I certify that I have re application and state that the TOTAL FEE 67• 0
above information is cor ect I gree to comply with all County _ �.
ordinancand State 1 kT regulating Electrical wiring and
hereby horize repre a tatives of this County to enter upon _
the a mentioned p op ty or inspect on purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date 1 '