HomeMy Public PortalAbout4833, 4825AGNES AVE_Electrical WORKERS COMPENSATION DECLARATION 63
CE 806G (2 80) APPLICATION FOR ELECTRICAL PERMIT
CE
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 i
a certified copy thereof(Sec 3800 Lab C) 3
5 5011 5STATE COMPENSATION FOR APPLICANT TO FILL IN JOB Policy No Company EACH NO FEE ADDRESS 4825WA AGNES
aINS New Residential Bldgs &Pools
Certified copy is hereby furnished 1 &2 Family Sq Ft 1,200 $ 02 — $ 0 00 LOCALITY TEMPLE CITY
Multifamily Sq Ft NEAREST
AUCertified copy is filed with the county building inspection CROSS ST rJZta-liiJ
department Residential Swimming Pools OWNER OR GEORGE WIEGAND
Date 7 Q 8 Applicant JERRY'S ELECTRIC, IN FIRM NAME
outlets Rec_Light sw
First 20 ADDRESS 14-- MELANIE LANE
CERTIFICATE OF EXEMPTION FROM WORKERS Total No Additional CITY ARCADIA Tel No 445 2803
COMPENSATION INSURANCE >_
PLAN CHECK CL
i
(This section need not be completed if the work involved APPLICANT V
by the permit is for one hundred dollars ($100) or less) Lighting Fixtures First 20 t ADDRESS
Total No Additional W
I certify that in the performance of the work for which this CITY Tel No 0
Fixed Appliances Not Over 1 HP (—
permit is issued I shall notz employ any person in any manner PERMIT ()
so as to become subject to the Workers Compensation Laws Range_Heater D W APPLICANTLU
Oven _ Dryer_W M ADDRESS BOX 1 Z
Date Applicant Top _ FAU _W H 962 9188
Hood — Fan —Other CITY BALDWIN PARK Tel No
NOTICE TO APPLICANT If after making this Certificate of Disp _Room Air Cond_ LICENSE OR
Exemption you should become subject to the Workers REG NUMBER — 02 lass C-10
Compensation provisions of the Labor Code you must forth Power Apparatus& Large Appliances DISTRICT NO PROCES D BY
with comply with such provisions or this permit shall be 1
deemed revoked Size&Type HP KW KVA or KVAR 5 f
Up to 1 Incl
1 Over 1 to 10 Incl DATE ` � J
1 LICENSED CONTRACTORS DECLARATION Over 10 to 50 Incl 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
effectServices
License NumbetC—10259475 Lic Class C-10 4 0 200 Amp Under 600 V
201 1000 Amp Under 600 V
ContractoPIERRY'S ELECTR q, INC 7-10-80 Over 1000 Amp or Over 600 V
HOME OWNER BUILDER DECLARATION Temp Power Pole&Appurtenances
I hereby affirm that iI am exempt from the Contractors Sign with One Branch Circuit
License Law for the following reason (Section 7031 5 Busi Additional Sign Branch Circuits
ness and Professions Code)
11 i Misc Conduits&Conductors
E] I as owner of the property will do the work and the Other(See Complete Fee Schedule)— :2 12 9 3 A
structure is not intended or offered for sale (Section t
7044 Business and Professions Code) t # o e o e o 2
CONSTRUCTION LENDING AGENCY It
I hereby affirm that there is a construction lending agency ' ` 2 0 0 3 7 6 0
for the performance'of the work for which this permit is PERMIT FEE (Sub Total) t
issued(Sec 3097 Civ C) 30 CC i o o o 3 7 0 0 0=
Lender s Name PLAN CHECKING FEE (One Fourth Permit Fee) ' 0716-80
� 4 �
Lender s Address PERMIT ISSUING FEE
7-00
I certify that I have read this application and state that the TOTAL FEE 37 00
above information is correct ee to comply with all County
i
RE
te laws regating Electrical wiring and
presents Ives f this County to enter upon
pro er f inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE r �
—10-60 ' t
Signature of Permittee V Date 1