HomeMy Public PortalAbout4833, 4825AGNES AVE_Electrical (12) WORKERS COMPENSATION DECLARATION 63
i CE APPLICATION FOR ELECTRICAL PERMIT
CE 8 806G (2 80)
I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES T BUILDING AND SAFETY
insure or a certificate of Workers Compensation Insurance or t l y
a certified copy thereof(Sec 3800 Lab C)
550115 STATE COMPENSATION f FOR APPLICANT TO FILL IN' JOg
�
Policy No Company EACH NO FEE ADDRESS 4833 A & B AGNES
INS FUND New Residential Bldgs &Pools
+� Certified copy is hereby furnished 1&2 Family Scl Ft 2.400 $ 025 — $ 60 LOCALITY TEMPLE CITY
Multifamily Scl Ft — NEAREST
Certified copy is filed with the county budding inspection CROSS ST "eA, `
department Residential Swimming Pools OWNER OR
* FIRM NAME GEORGE WIEGAN
Date 7_10-8C Applicant JEMY'S RT TRT ,THTC Outlets Rec,—Light Sw MAIL
First 20 ADDRESS 1425 MELANIE LANE
CERTIFICATE OF EXEMPTION FROM WORKERS Total No Additional CITY
t COMPENSATION INSURANCE f i f ARCADIA Tel No 445 2803 a
PLAN CHECK O
(This section need not be completed if the work mvolved r APPLICANT V
by the permit is for one hundred dollars ($100) or less) Lighting Fixtures First ADDRESS cc
+ Total No Additional 0
I certify that in the 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 z PERMITJERRY'S ELECTRIC INC W
so as to become subject to the Workers Compensation Laws Range_ Heater D W APPLICANT d
Oven _ Dryer_W MADDRESS BOX 1 Z
Date Applicant Top _ FAU _W H
Hood _ Fan _OtherCITY BALLWIN PARK Tel No i 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 lass
Compensation provisions of the Labor Code you must forth Power Apparatus& Large Appliances DISTRICT NO PROCESSED BY
with comply with such provisions or this permit shall be
deemed revoked Size&Type HP KW KVA or KVAR
Up to 1 Incl
FINAL 601
�_ y�_
LICENSED CONTRACTORS DECLARATION Over 1 to 10 Incl I DATE` VALIDATION
Over 10 to 50 Incl
I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc FINAL 1 `
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
0 200 Amp Under 600 V
License NumbeY�10259475 L,� Class C�10 201 1000 Amp Under 600 V
Contractor .TERRY'S ELE(.'T go INC, 7-10-80 Over 1000 Amp or Over 600 V
` f
HOME OWNER BUILDER DECLARATION
Temp Power Pole&Appurtenances t �
-.11 Sign with One Branch Circuit i
I hereby affirm that I am exempt from the Contractors l
License Law for the following reason (Section 7031 5 Busi Additional Sign Branchk,Circuits 2 1 2 9 0 A
Hess and Professions Code) -
i Misc Conduits&Conductors f - i# o o a 010 2 a
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 2 0 6 7 0�0
7044 Business and Professions Code) t r
CONSTRUCTION LENDING AGENCY loo 0 6`] 0 0 czi
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is r
PERMIT FEE0716-80
issued(Sec 3097 Civ C) (Sub Total) qim
M
Lender s Name PLAN CHECKING FEE (One Fourth Permit Fee) -
Lender s Address PERMIT ISSUING FEE
0
I certify that I have read this p cation and state that the TOTAL FEE 67 00
above information is correct agree o comply with all County ^
ordinances and State laws legulating Electrical wiring and
hereby au rize representi es of his County to enter upon
the ab mentioned prope y or spection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE �
10-80
Signature of Permittee Date
i .. t