HomeMy Public PortalAbout4936 SERENO DR_Electrical__ 1 ' I d I ; 1 1 1 1 II
APPLICAW FUL INHEAVEHEAVELY OUTLUVW POI; 1 1
DESCREMON OF WORK
NUMDKR
.F OUTLrM ON CIRCUITGLOCATION IW ROOMS
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E WAR RAM REIM
APPEICAMr
FILL INHEAVELY PORnON ONLY
DESCRIEPHON OF WORK
LOCATION BY RCK)M9
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FriMEIN IN MEMS
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affirm
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COMPENSATION DECLARATION 7 G Lo.B, APPLICATION FOR ELECTRICAL PERMIT
I l�erdby affirm that 1 have a certificate of consent to self �'�C
insure or a certificate of Workers Compensation Insuronce ' "''COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified copy thereof (Sec 3800 Lab C )
Policy No Company FOR APPLICANT TO FILL IN JOB 12 1
r ,Q D
Certified copy is hereby furnished New Residential Bldgs & Pools EACH NO FEEl• 7
Certified copy is filed with the county budding mspec I & 2-Family Sq Ft f — S LOCALITY
hon department Multi family Sq Ft — NEAREST
Residential Swimming Paola - CROSS ST
Date Applicant r C r1
CERTIFICATE OF EXEMPTION FROM WORKERS FIRM NAME Outlets Re Light_J Sw , MAIL 6/
COMPENSATION INSURANCE ADDRESS 1121
(This section need not be completed if the work Imolr•d by First 20
the permit Is for one hundred dellors($100)or less ) Total No i-L Additional CITY -,S �23 pr Tel No,,7gf=IJ
I certify that in the performance of the work for which this RAN CHECK
permit is issued I shall not employ any person in any manner RICANT
so as to become subject to the rkers Compensation ws Lighting Fixtures Fust 20 r ADDRESS
Total No� Additional
r CIN Tel No
Date pplica Fixed Appliances Not Over 1 HP PERMIT
J� NOTICE TO APPLI NT If a king rthis Certificate o Ran e_ Heater_D W — APRtCANT
1 `Exemption you should becom sublect to the Workers' 9
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 —W H
r deemed revoked Hood _ Fan _Other— CITY Tel No
LICENSED CONTRACTORS DECLARATION pisp _ Room Au Cored LICENSE OR
I hereby affirm that I am licensed under provisions of Chapter 9 ' REG NUMBER Class
(commencing with Section 70DD) of Division 3 of the Business Power Apparatus 8 Large Appliances DISTRICT NO PROCESSED BY
and Professions Code and my license Is In full force and effect - d
Size 8 type HP KW KVA or KVAR O
License Number Lic Class Up to 1 Incl FINAL V
Over I to 10 Incl DATE 09
Contractor Date 1� VALIDATION 0
r_1Over 10 to 50 Incl FINAL tJ
I am exempt under Sec Over 50 to 100 Inc BY
W
B BP C for this reason °r 100 us
Services Swbd, MCC B Ponelboards ► Z
Dote 0 -200 Amp Under 600 V
Signature 201 - 1000 Amp Under 600 V
O -
Exemption for Reg Maint Elect Over 1000 Amp or Over 600 V
' SINGLE FAMILY Temp Power Pole 8 Appurtenances
HOME OWNER BUILDER DECLARATION Sign with One Branch Circuit I hereby affirm that I am exempt from the Contractor s License Additionalwith
One
Branch ircuitCircu1 2 5 Q,9 A
Law for the following reason (Section 7031 5, Business and
Professions Code)
# •,• •,•,• 2
as owner of the property, will the work and the Misc Conduits BConductors
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)— , 2 • - 5025
7044,�Busvness and Professions Code)
- is t• 502'54
CONSTRUCTION LENDING AGENCY _
I hereby affirm that there is a construction lending agency for7 0 b—8 4
the performance of the work for which this permit is issued - PERMIT FEE (Sub-Totol)
(Sec 3097, Civ C )
+ PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE
Lender s Address r
I certify that I have read this application and statethat the TOTAL FEE
above information is correct I agree to comply with all County
ordinances and State laws regulating Electrical wiring and _
hereby authorize represe tahves of this County to enter upon - -
t to above-mentioned p arty for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
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Sigfature of Form itlee Date