HomeMy Public PortalAbout4831AGNES AVE_Electrical (4) WORKERS COMPENSATION DECLARATION 63
CE 806G (2 80) APPLICATION FOR ELECTRICAL PERMIT
" CE 8
I hereby affirm that 1 have a certificate of consent to self COUNTY OF LOS ANGELES �7'- BUILDING AND SAFETY
insure or a certificate of Workers Compensation Insurance or / ,
a certified copy thereof(Sec 3800 Lab C)
Policy No950115 Company
STATE COMPENSATION FOR APPLICANT TO FILL IN SOB
New Residential Bldgs &Pools EACH NO FEE ADDRESS 4831 D & C AGNES
Certified copy is hereby furnis e ' D 1 &2 Family Scl Ft 2,400 $ • '- $ • LOCALITY
TEMPLE CITY
111)
Multi family Scl Ft NEAREST - � l /
Certified copy is filed with the county building inspection CROSS ST O-A� LQ.LCJ
department Residential Swimming Pools OWNER OR GEORGE WIEGAND'
Date 7-10-80 App►icantJERRY'S ELECTRIC, INC FIRM NAME
Outlets Rec_Light Sw ADDRESS First 20 ESS 1 2 MELANIE LANE
CERTIFICATE OF EXEMPTION FROM WORKERS Total No Additional CITY ARCADIA Tel No 445 2803
COMPENSATION INSURANCE
� PLAN CHECK d
O
(This section need not be completed if the work involved APPLICANT U
by the permit is for one hundred dollars ($100) or less) Lighting Fixtures First 20 ADDRESS 1 tx
Total No Additional O
1 certify that in the performance of the work for which this Fixed Appliances Not Over 1 HP CITY _ Tel No U
permit is issued I shall not employ any person in any manner PERMIT-
soINC.as to become subject to the Workers Compensation Laws Range_Heater D W APPLICANT f a
Oven _ Dryer_W My
ADDRESS BOX 159
Date Applicant Top _ FAU _W H ? i
Hood _ Fan _Other_ CITY BALDWM PARK Tel No 62 9188
NOTICE TO APPLICANT If after making this Certificate of Disp _Room Air Cond_ LICENSE OR C 1025947L5, C-10
Exemption you should become subject to the Workers REG NUMBER ass
Compensation provisions of the Labor Code you must forth Power Apparatus& Large Appliances DISTRICT NO PROCES XD 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 FINAL
LICENSED CONTRACTORS DECLARATION DATE _ _ VALIDATION
Over 10 to 50 Incl
I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc FINALBY
1t k
9 (commencing with Section 7000) of Division 3 of the Busi Over 100
ness and Professions Code and my license is in full force and r c-
effect Services
`License NumberD-10259A35Lic Class C-10 0 200 Amp Under 600 V � i
201 1000 Amp Under 600 V
ContractoElIMIRYtE FTFY'! RMQS TNC_ 7-10-80 Over 1000 Amp or Over 600V Y'
v
` HOME OWNER BUILDER DECLARATION Temp Power Pole&Appurtenances
I hereby affirm that I am exempt from the Contractors Sign with One+Branch Circuit /
h C
B
Sign Branch Circuits
License Law for the following reason (Section 7031 5 Busi Additional Other
-21 2 8.9 A ►
nese and Professions Code) i
I as owner of the property will do the work and the Conduits&Conductors l
Other(See Complete Fee Schedule)—
structure is not intended or offered for sale (Section r 2 0 96700
f
7044 Business and Professions Code)
CONSTRUCTION LENDING AGENCY o • 0 0 6 7 0 0=
I hereby affirm that there is a construction lending agency J v
for the performance'of the work for which this permit is PERMIT FEE (Sub Total) '
issued(Sec 3097 Civ C) i 60.00 0 7 1 6y-80
Lender s Name PLAN CHECKING FEE (OneiFourth Permit Fee)
Lender s Address PERMIT ISSUING FEE 7 QQ
� \ i
I certify that I have read this application and state that the TOTAL FEE
above information is correctIreu
to comply with all County
ordinances a State lawsing Electrical wiring and + N
herebyut ne representathis County to enter upontheab entioned prop rspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
0-80 ,
Signature of Permittee Date + j