HomeMy Public PortalAbout9015 EMPEROR AVE_Electrical__ i
WORKERS'COMPENSATION DECLARATION
CE-806G (2-80) APPLICATION FOR ELECTRICAL PERMIT
" CE-806
I hereby affirm that I have a certificate of consent to,self COUNTY OF LES BUILDING AND SAFETY
insure, or a certificate of Workers'Compensation Insurance,or T le Cit
a certified copy thereof(Sec. 3800,Lab. C.) � y
550115- St,,=tP F7mn FOR APPL LL IN JOB
Policy No. mpany EACH NO. FEE ADDRESS 5 7
New Residential Bldgs.&Pools O.
E] Certified copy is hereby furnished. 1 &2-Family,sq. Ft. 21960 $ Q — $ 878 an LOCALITY Temple City
Multi-family Sq. Ft. — NEAREST
-� Certified copy is filed with the county building inspection CROSS ST
Residential Swimming Pools OWNER OR
department. FIRM NAME Richard Renner
Date 1/23 e4plicant Jerry': hlec`-ic, In Outlets: Rec._Light_Sw. MAIL
First 20 ADDRESS 7501 Sarabeth St
CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. Additional CITY Dovme Tel No. 928-6911
COMPENSATION INSURANCE PLAN CHECK CL
O
(This section need not be completed if the work involved APPLICANT U
by the permit is for one hundred dollars ($100) or less.) Lighting Fixtures First 20 ADDRESS c1c
Total No. Additional
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 PERMIT
so as to become subject to the Workers' Compensation Laws. Range— Heater_D.W.,_ APPLICANT Jer 'S Electric Inc. 0.
Oven _ Dryer_W.M. ADDRESS Z
Top _ FAU _W.H.._ Baldwin Park 962-9188
Date Applicant CITY Tel-No.
Hood — Fan —Other
NOTICE TO APPLICANT: If, after making thisCertificate of Disp. _ Room Air Cond._ LICENSE OR
Exemption, you should become subject to .the Workers' REG.NUMBER 259475 Class
Compensation provisions of the Labor Code, you must forth- Power Apparatus& Large Appliances DISTRICT NO. PROCE ED By
with cbmply with such provisions or this permit shall be Size&Type HP, KW, KVA,or KVAR [� (y
deemed revoked. J Q
Up to 1 Incl. �
' FINAL
Over 1 to 10 Inc]. DATE
LICENSED CONTRACTORS DECLARATION Over 10 to 50 Incl. VALIDATION
I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. FINA
BY
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. Services
License Number 25975 Lic.Class CIQ 0-200 Amp. Under 600 V
201-1000 Amp. Under 600 V
Contractor Jerry'S elee.Date 1/23/84 Over 1000 Amp.or Over 600 V _ I
HOME OWNER-BUILDER DECLARATION Temp. Power Pole&Appurtenances
I hereby affirm that I am exempt from the Contractor's Sign with One Branch Circuit t
License Law'for the following reason (Section 7031.5, Busi-
ness and Professions Code):
Misc.Conduits&Conductors -
❑ 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).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is PERMIT FEE (Sub-Total)
issued (Sec.,3097,Civ.,C.). 878.40
Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee)
Lender's Address PERMIT ISSUING FEE
10.5
I certify that I have read this application and state that the TOTAL FEE
above information is correct.I agree to comply with all County f
ordinances and State laws regulating Electrical wiring, and
hereby authorize representatives of this County to enter upon
the abov �ned' rty for' spection purposes. SEE'REVERSE FOR EXPLANATORY LANGUAGE
23 84
Signature of Permittee Date