HomeMy Public PortalAbout4833, 4825AGNES AVE_Electrical (9) WORKERS COMPENSATION DECLARATION 76A66G (280) ' APPLICATION FOR ELECTRICAL PERMIT
CE 80I r
I hereby affirm that I havea certificate of consent to self COUNTY OF LOS ANGELES C BUILDING AND SAFETY
insure or a certificate of Workers Compensation Insurance or l
a certified copy thereof(Sec 3800 Lab C)
Policy No 550115 CompanSTATE COMPENSATION FOR APPLICANT TO FILL IN JOB 4833 C & D AGNES
y
New Residential Bldgs &Pools EACH NO FEE ADDRESS
ElCertifiedcopy is hereby furnished FUNDNew
&2 Family Sq Ft 2.400 $ 025 Is 60 CU LOCALITY TEMPLE CITY
Multifamily Sq Ft NEAREST
E(Certified copy is filed with the county building inspection CROSS ST Q2, fig/
department Residential Swimming Pools OWNEROR Wl@ 6T1C�
7-10-80 JERRY'S ELECTRIC, INCFI RM NAME g
Date Applicant Outlets Rec_Light it 20 ADDR
First ESS 1425 MELANIE LANE
CERTIFICATE OF EXEMPTION FROM WORKERS Total No Additional CITY ARCADIA Tel No 445 2803
COMPENSATION INSURANCE + PLAN CHECK O}.
(This section need not be completed if the work involved Lighting Fixtures First 20 APPLICANT V
by the permit is for one hundred dollars ($100) or less) g g Additional ADDRESS
I certifythat in the Total No O
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 in any manner PERMITU
so as to become subject to the Workers Compensation Laws Range_Heater D W APPLICANT JERRY'S ELECTRIC9 INC iII
W Oven _ Dryer_W M ADDRESS Z
Date Applicant Top _ FAU _W H 130X 159_
Hood _ Fan —Other_ CITY BALDWIN PAM Tel No 962 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 NUMBER C-10259475Iass C-10
Compensation provisions of the Labor Code you must forth Power Apparatus& Large Appliances DISTRICT NO PROCES,§ED BY
with comply with such provisions or this permit shall beV e
deemed revoked Size&Type HP KW KVA or KVAR
Up to 1 Incl
FINAL
Over 1 to 10 Incl DATE i
LICENSED CONTRACTORS DECLARATIONVALIDATION
Over 10 to 50 Incl
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
effect Services
License NumbeP-10259475 Lic Class C-10 0 200 Amp Under 600 V `�L7
201 1000 Amp Under 600 V `
ContractonTRRRY I S FT,r(.TRT t o_ INC, 7-10-80 Over 1000 Amp or Over 600 V ' rO
HOME OWNER BUILDER DECLARATION Temp Power Pole&Appurtenances
I hereby affirm that I am exempt from the Contractors Sign with One Branch Circuit r 2 1 2 9 1 A
License Law for the following reason (Section 7031 5 Busi Additional Sign Branch Circuits
ness and Professions Code)
1# 0 a a c o 2
I aMisc Conduits&Conductors 2 o o 6 7 0 0
owner of the property will do the work and the , Other (See Complete Fee Schedule)—
structure
ture is not intended or offered for sale (Section o 0 0 6 7 0 0 v
7044 Business and Professions Code)
CONSTRUCTION LENDING A(aENCY i
I hereby affirm that there is a construction lending agency 0 7 16-80
for the performance of the work for which this permit is b Tota
PERMIT FEE (Sul)
issued(Sec 3097 Civ C) 60 MO
Lender s Name PLAN CHECKING FEE (One Fourth Permit Fee)
Lender s Address
PERMIT ISSUING FEE 70
I certify that I have read this application and state that the TOTAL FEE 67 0
above information is correc ree to comply with all County
ordinances and State law re ulating Electrical wiring and
hereby aut rize represent five of this County to enter upon i
the ab v entioned pr per y r inspection purposes ` SEE REVERSE FOR EXPLANATORY LANGUAGE �
Signature of Permittee Date
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