HomeMy Public PortalAbout4922 SERENO DR_Electrical__ WORKERS' COMPENSATION DECLARATION �,o�arBT APPLICATION FOR ELECTRICAL PERMIT O
I hereby affirm that I have a certificate ate of consent to s ��
insure 'w a certificate of Workers Cgm'pensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
or a certified copy thereof (" 3800 Lab C )
P lacy No Company FOR APPLICANT TO FILL IN JOB
Certified copy is hereby furnished New Residential Bldgs 8 Pools EACH NO FEE ADDRESS Os
rtified co $ - — $ LOCALITY
py is filed with the county building inspec- 1 8 2-Family, Sq Ft
tion department Multi family Sq Ft — NEAREST
Residential SwimmingPools CROSS ST
Dote —Applicant OWNER OR
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS OutMAIL
Outlets R°c_Light_$w
COMPENSATION INSURANCE � ADDRESS -
(Thu section need not be completed H the work Irwolred by Total No First 20 CIN Tel No
the permit Is for one hundred dollars($100)or less) Additional
RAN CHECK
I certify that in the performance of the work for which this APPLICANT
permit is issued, I shall not employ any parson in any manner
so as to ons subject to the Workers Compensation Laws Lighting Fixtures First 20 ADDRESS
Jsn,� AdditionalDote/ /v 9 Applicant /'+'�2 T,Q� Total No CITY - Tel No
Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT If °her making this Certificate of Range— Heater—D W — APPLICATION
Exemption you should become subject to the Workers
Compensation provisions of the Labor Code you must forth- Oven _ Dryer W M — ADDRESS
with comply with,such provisions or this permit shall be Top FAU —WH --L CITY Tel No
deemed revoked Hood — Fan —Other_
LICENSED CONTRACTORS DECLARATION . Disp _ Room Air Cond _ LICENSE OR Clan
hereby affvm that I am licensed under provisions of Chapter 9 REG NUMBER
(commencing with Section 7000)of Division 3 of the Business Power Apparatus 8 Large Appliances DISTR�CT�1O PM Y Y
and Professions Code,and my license is in full force and effect - s D.Size Type HP, KW, KVA, or KVAR �J Q
License Number �_ZzV Li< Clan �/J�� Up to 1 Incl FINAL V
Contractor /V/(� ��ate 9d Ovar I to 10 Ind DATE rOf D VALIDATION 0O
❑ Over 10 to 50 In " H
I ons exempt under Sec a Over 50 to 100 Inc BY LU
B 8P C for this reason Over 100ITY, Q.
►
Date Services, $solid , MCC 8 Panelboards N
Z
0-200 Amp Under 600 VTV
Signature i 201 - IODD Amp Under 600 V -
❑ Over 1000 Amp or Over 600 V
Exemption for Reg Moint Elect _ _
SINGLE FAMILY Temp Power Pole&Appurtenances 2
HOME OWNER BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor s License Sign with One Branch Circuit
Law for the following reason (Section 7031 5 Business and Additional Sign Branch Circuits ' ] A43.Ck1
Professions Code)
❑ I as owner of the property will do the work and the Mix Conduits 8 Conductors 1 ITBIS
structure is not intended or offered for sale(Section 7044, Other(See Complete Fee Sch°dule� ' TOTAL 43 .00
Business and Professions Coda) 1
43.10
CONSTRUCTION LENDING AGENCY
LF�CK
I hereby off irm that there is a construction lending agency for CHANCE •O(I
the performance of the work for which this permit is issued t PERMIT FEE (Sub-Total)
(Sec 3047, Civ C ) �- _ t _
PIAN CHECKING FEE 0000-MOI 110/90
Lender s Name '
PERMIT ISSUING FEE 81087 1 An 9:✓4
Lender s Address
I certify that I hove read this application and state that the TOTAL FEE
4 A:3O
above information is correct I agree to comply with all County - -
ordinances and State lows regulating Electrical wiring, and
hereb authorize representatives of this County to enter upon
t P -mentione properq fo nspectiopun sea SEE REVERSE FOR EXPLANATORY LANGUAGE
Si ature of Permittee Date ms