HomeMy Public PortalAbout10529 BOGUE ST_Electrical__ WORKERS'COMPENSATION DECLARATION CE-806 10/81 APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self CE-806G
insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified copy thereof (Sec. 3800, Lab. C.)
PolPolicy No.-95,� 1 5—�4mpany Stam i--c- Fund FOR APPLICANT TO FILL IN JOB 10529 BOque
Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADDRESS
LOCALITY
[:�XCertified 1 & 2-Famil copy is filed with the county building inspec- y, Sq. Ft. 1949 $ .04-- $ le Cl
tion department. Multi-family Sq. Ft. NEAREST
r Residential Swimming Pools CROSS ST.
Date
4113184 Applicant Jerry' .-, P�PC tr c, OWNER OR FIRM NAME Jack Owens
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw. ADDRESS 4265 Baldwin Ave
COMPENSATION INSURANCE First 20
(This section need not be completed if the work involved by Total No. Additional CITY El Monte, Ca. Tel. No. 443-0078
the permit is for one hundred dollars ($100)or less.)
PLAN CHECK
I certifythat in the performance of the work for which this
e P APPLICANT
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS
Additional
Total No. CITY Tel. No.
Date Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT J r
Exemption, you should become subject to the Workers' Range_ Heater_D.W.
Compensation provisions of the Labor Code, you must forth- Oven _ Dryer — W.M.— ADDRESS P. 0._BOX 159
with comply with such provisions or this permit shall be Top _ FAU —W.H. —
deemed revoked. Hood _ Fan _Other_ CITYBaldwin Park., _A I. No. 962-918
LICENSED CONTRACTORS DECLARATION LICENSE OR
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. _ Room Air Cond. REG. NUMBER Class.
(commencing with Section 7000) of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO. PROCESSED BY
and Professions Code,and my license is in full force and effect.
Size &Type HP, KW, KVA, or KVAR0
License Number, 259475 Lic. Class C10 Up to 1 Incl. FINAL g� ✓
r Over 1 to 10 Incl. DATE Ce��9 VALIDATION
Contractor Jerry s Elecb 1e 4/13/84❑ 0
Over 10 to 50 Incl. FINAL
1 am exempt under Sec. Over 50 to 100 Inc. BY C D ,y LLI
B.&P.C. for this reason Over 100
Services, Swbd., MCC & Panelboards LPI 8`9. A K
Date: 0 -200 Amp. Under 600 V
Signature 201 - 1000 Amp. Under 600 V t o t o� q .8.6
❑ Amp. y Exemption for Reg. Maint. Elect. Over 1000 or Over 600 V ,o•o'o � 30=
t � •
SINGLE FAMILY Temp. Power Pole &Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License Additional Sign Branch Circuits
Law for the following reason (Section 7031.5, Business and
Professions Code):
❑ I, as owner of the property, will do the work and the Misc. Conduits &Conductors
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) 77.180
(Sec. 3097, Civ. C.).
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE
Lender's Address
I certify that I have read this application and state that the TOTAL FEE 88. 30
above information is correct. I agree to comply with all County
ordinances and State laws regulating Electrical wiring, and
hereby authorize repre tative this County to enter upon
bove-mentioned ro rty or spection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
_ 1
"Signature of Permittee Date