HomeMy Public PortalAbout4833, 4825AGNES AVE_Electrical (10) J
WORKERS COMPENSATION DECLARATION CE 8 63 APPLICATION FOR ELECTRICAL PERMIT
.- CE 806G (2 801
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I hereby affirm that 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 Cr ! i
STATE
Poliy No 550115 CompanyCOMPENSATION _ FOR APPLICANT TO FILL IN JOB
ADDRESS $2, D E AGNES
New Residential Bldgs &Pools EACH NO FEE
E] Certified copy is hereby furnished 1&2 Family Sq Ft -2"0 $ — $ LOCALITY TEMPLE CITY 47
Multi family Sq�-Ft ' NEAREST
EICertified copy is Bled with the county building inspection w CROSS ST
department a Residential Swimming Pools
OWNER OR
t FIRM NAME GERG WIEGAND
Dat -10-80 A licant��YtS ELECTRIC, INC ADDRESS 1425-MELANIE LANE
7 PP Outlets Rec_Light Sw MAIL
First 20
CERTIFICATE OF EXEMPTION FROM WORKERS Total No Additional CITY ARCADIA Tel No280 }
COMPENSATION INSURANCE
PLAN CHECK r 110'
APPLICANT V
(This section need not be completed if the work mvolved r
by the permit is for one hundred dollars ($100) or less) Lighting Fixtures First 20 ADDRESS
cc
Additional
I certify that in the performance of the work for which this Total No I CITY Tel No U
permit is issued I shall not em person in any manner Fixed Appliances Not Over 1 HP
P employ Y an Y P PERMIT
so as to become subject to the Workers Compensation Laws Range_Heater D W APPLICANT JERRY'S ELECTRIC,* INC pW.
I Oven _ Dryer_,W MADDRESS Box 159 i ?
Date Applicant Top — FAU _W H _ CITY BALDWIN PARK Tel No 962 9188
Hood _ Fan —Other
NOTICE TO APPLICANT If after making this Certificate of Disp _ Room Air Cond_ LICENSE OR C-102 p C-10
Exemption you should become subject to the Workers REG NUMBER 59`t7%lass
Compensation provisions of the Labor Code you must forth Power Apparatus& Large Appliances DISTRICT NO PROCEWIED By
with comply with such provisions or this permit shall be '
deemed revoked Size&Type HP KW KVA or KVAR �i�
Up to 1 Incl 1 -
FINAL
LICENSED CONTRACTORS DECLARATION Over 1 to 10 Incl DATE ` L/, VALIDATION
_ G/
Over 10 to 50 Incl !l
I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100E Inc FINALBY t �
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
effect C-102594Services
License Number 7 C-10 0 200 Amp Under 600 V - - i
is Class
JERRY'S ELECTRIC INC 7-10-80 201 1000 Amp Under 600 V .2S y� 21 2 9 5 A+
Contractor Date Over 1000 Amp or Over 600 V
0 0 0 0 0 2
HOME OWNER BUILDER DECLARATION` Temp Power Pole&Appurtenances +
i
I hereby affirm that I am exempt from the Contractors Sign with One Branch Circuit 2 - - 6 7 0 0Additional Sign Branch Circuits {
License Law for the following reason (Section 7031 5 Busi 0 0 0 67005
ness and Professions Code)
Mise Conduits&Conductors 0 -7 1 6-80
I as owner of the property will do the work and the Other(See Complete Fee Schedule)— "
structure is not intended or offered for sale (Section + +
7044 Business and Professions Code) r
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency
for the performance of the wgrk for which this permit is PERMIT FEE (Sub Total) j
issued(Sec 3097 Civ C) i
Lender s Name PLAN CHECKING FEE (One Fourth Permit Fee) S
Lender s Address
PERMIT ISSUING FEE 7- 20 el
r �
I certify that I have read this application and state that the TOTAL FEE 67 20
above information is correct I agree to comply with all County + !
ordinances and State law gulating Electrical wiring and y
hereby a Itorize represen tiv s of this County to enter upon
the abo mentioned p p ty for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE j
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Signature of Permittee a — i I
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