HomeMy Public PortalAbout4833, 4825AGNES AVE_Electrical (13) WORKERS COMPENSATION DECLARATION 63
CE 806G (2 80) APPLICATION FOR ELECTRICAL PERMIT
CE 8
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 r r` r b
a certified copy thereof(Sec 3800 Lab C) +
550115 STATE COMPENSATION FOR APPLICANT TO FILL IN JOB 4825 B & C AGNES
Policy No Company -Llqs POD New Residential Bldgs &Pools EACH NO FEE ADDRESS
Certified copy is hereby furnished r ) 1 &2 Family Scl Ft 2liAOo $ — $ bO 00 LOCALITY TEMPLE CITY
Multi family Scl Ft NEAREST
Inc Certified copy is filed with the county building inspection Residential Swimming Pools CROSS ST
department OWNER OR
7-10-80 JERRY'S ELECTRIC, INC FIRM NAME GEORGE WIEGAND
Date Applicant Outlets Rec_Light Sw ADDRESS 1425{MELANIE LANE
CERTIFICATE OF EXEMPTION FROM WORKERS First 20
Total No Additional " CITY AR(,'�� Tel No 445 2803
COMPENSATION INSURANCE ( PLAN CHECK d
(This section need not be completed if the work involved APPLICANT 0
by the permit is for one hundred dollars ($100) or less) Lighting Fixtures First 20 ADDRESS
i Additional =
Total No 0
I certify that in the performance of the work for which this Fixed Appliances Not Over 1 HP CITY Tel No I--
permit
permit is issued I shall not employ any person in any manner PERMITJERRY'S �,LECTRIC `INC W
so as to become subject to the Workers Compensation Laws Range_Heater D W APPLICANT ! tl
't Oven _ Dryer_W M r ADDRESS BOX 1 Coll
Z
Hood Fan Other_
Date Applicant Top _ FAU _W _ CITY BALDWIN PARK Tel No 962 9188 '
_
NOTICE TO APPLICANT If after making this Certificate of Disp Room Air Cond LICENSE OR C-10259475 i C-10 M
Exemption you should become subject to the Workers REG NUMBER Class
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 Size&
deemed revoked Type HP KW KVA or KVAR
Up to 1 Incl
Over 1 to 10 Incl DAT L i6i t
LICENSED CONTRACTORS DECLARATION a'-/
Over 10 to 50 Incl VALIDATION
I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc FINAL
BY
9 (commencing with Section 7000)of Division 3 of the Bust Over 100
ness and Professions Code and my license is in full force and
effectServices r
License NumberC-10259475Lic- Class C'-1 C i 0 200 Amp Under 600 ViJ `
201 1000 Amp Under 600 V ` n
Contractor JERRY S ELECTW1Qg INC 7-10-80 Over 1000 Amp or Over 600 V (o
T
HOME OWNER BUILDER DECLARATION Temp Power Pole&Appurtenances
a
I hereby affirm that I am exempt from the Contractors Sign with One Branch Circuit
License Law for the following reason (Section 7031 5 Bust Additional Sign Branch Circuits
ness and Professions Code)
•
Misc Conduits&Conductors r
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 t i
7044 Business and Professions Code) i 1 2 9 4 A
"CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency x + # o a o a a 2 t
for the performance of the work for which this permit is 'PERMIT FEE r (Sub Total) 60 0
issued(Sec 3097 Civ C) i 4 f2 — 6700
Lender s Name PLAN CHECKING FEE (One Fourth Permit Fee) • o i6 7Q
0
Lender s Address CE
PERMIT ISSUING FEE a 7
I __ 0716-80
I certify that I have read this application and state that the TOTAL FEE 67 h0J `
above information is correct I agree to comply with all County
t
ordinances and State Is
r�or
gulating Electrical wiring and �
hereby au orize represe tativs of this County to enter upon f 1T t
the abov entioned pr rty inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
7-10-80 I
Signature of Permittee Date
1