HomeMy Public PortalAbout4833, 4825AGNES AVE_Electrical (7) WORKERS COMPENSATION DECLARATION 63
CE 806G (2 801 APPLICATION FOR ELECTRICAL PERMIT
CE 8 \
I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES �C 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 SOB /
I t New Residential Bldgs &Pools EACH NO FEE ADDRESS 4833 E AGNES
Certified copy is hereby furnished 1 &2 Family Scl Ft -1.400 $ 02 — $ 35.00 LOCALITY TEMPLE CITY
y g p
Multifamily Scl Ft — NEAREST
Certified co
py is filed with the count building inspection Residential Swimming Pools CROSS ST
department OWNER OR
7-10-80 JERRY'S ELECTRIC, INCFIRM NAME GEORGE WIEGAND
Date Applicant i First 20 Outlets Rec—Light Sw ADDRESS �
CERTIFICATE OF EXEMPTION FROM WORKERS Total No Additional CITY ARCADIA Tel No 2803 >_COMPENSATION INSURANCE PLAN CHECK t IL
APPLICANT O
(This section need not be completed if the work-involvedLighting Fixtures First 20 i C)
by the permit is for one hundred dollars ($100) or less) ADDRESS �
Total No Additional
I certify that in the performance of the work for which this Fixed Appliances Not Over 1 HP CITY J Tel No U
permit is issued I shall not employ any person in any manner PERMIT
so as to become subject to the Workers Compensation Laws Range_Heater D W APPLICANT JERRY'S ELECTRIC INC d
Oven _ Dryer_W M _ ADDRESS Box 159 z
Date t Applicant Top _ FAU _W H
i Hood _ Fan _Other_ CITY iBALDWIN PARK Tel No 62 9188
NOTICE TO APPLICANT If after making this Certificate of Disp _ Room Air Cond_ LICENSE OR
Exemption you should become subject to the Workers REG NUMBEFC+-102 Class C-10
Compensation provisions of the Labor Code you must forth Power Apparatus& Large Appliances DISTRICT NO PROCES D BY6
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 — �.f_ g/ VALIDATION)
Over 10 to 50 Incl
I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc FINAL t
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
effect Services
10259475 C-10 0 200 Amp Under 600 V
License Numbe�— Li. Class 201 1000 Amp Under 600 V
ContractorJERRY'S FTF:CTFdW% INC. 7-10-80 Over 1000 Amp or Over 600 V
HOME OWNER BUILDER DECLARATION Temp Power Pole&Appurtenances -{
I hereby affirm that I am exempt from the Contractors Sign with One Branch Circuit a
License Law for the following reason (Section 7031 5 Busi Additional Sign Branch Circuits
ness and Professions Code)
I as owner of the property will do the work and the Misc Conduits&Conductors Al 2 9 2 AOther(See Complete Fee Schedule)—
structure is not intended or offered for sale (Section # 0 0 0 0 0 2
7044 Business and Professions Code)
CONSTRUCTION LENDING AGENCY i 2 - 4200 0 4 2 0 0
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permittis PERMIT FEE (Sub Total) 00 0 0 0 (� 2 _
issued(Sec 3097 Civ C) 35 c3
Lender s Name PLAN CHECKING FEE (One Fourth Permit Fee) r 0 7 1 6-8'0
Lender s Address _ PERMIT ISSUING FEE 7OQ r
I certify that I have read this application and state that the TOTAL FEE f 42 00 `
above information is correct I agree to comply with all County
ordinances,and State laws re ulating Electrical wiring and l t
hereby a horize representati es of this County to enter upon
the a v mentioned prop rt fo inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
&L—q=10-80 i
Signature of Permittee Date