HomeMy Public PortalAbout5038 SERENO DR_Electrical__ WORKERS COMPENSATION DECLARATION ID,eI ' APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consentCE-806 tQ sglf �-�
insure or a certificate of Workers Compensation Insurance COUNTY OF LOS ANGELES r C-,, BUILDING AND SAFETY
or a certified copy thereof (Sec 3800 Lab C ) `
Policy No Company FOR APPLICANT TO FILL III AODDg RE55 0�
Certified copy a hereby furnished New Residential Bldgs 8 Pools �'� NO FEE
❑ Certified copy is filed with the county building mspec 1 8 2-Family Sq Ft f — f LOCALITY
non department - Multi family Sq Ft — NEAREST
CROSS ST Q LL C
Residential Swimming sols OWNER OR _
Dote Applicant FIRM NAME /1./2
CERTIFICATE OF EXEMPTION FROM WORKERS Outlets Rec�Light�Sw MAIL
COMPENSATION INSURANCE .� ��j First 2d Z17 ADDRESS
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(This section need not be completed If the work Irwolvod by Total No�L Additional CITY �l f Tel No
the permit Is for one hundred dollars ($100)or loss)
I certify that in the performance of the work fee which this PLANL4N
APPLICAE
CK
permit is issued I shall not employ any person in any manner_
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so as to become subject to the Workers Compensation Laws Lighting Fixtures First 20 S b ADDRESS
Date 0 hcant r — Additional CITY Tel No
/ d7�^ p � / _/�js(� Total No
NOTICE O A LICANT If after making this Certificate of Fixed Appliances Not Over 1 HP PERMIT
Exemption you should become subject to the Workers' Range_ Heater_D W APPLICANT
Compensation provisions of the Labor Code you must forth- .Oven _ Dryer _ W M ADDRESS
with comply with such provisions or this permit shall be _
deemed revoked Hood _ Fan Ot H CITY Tel No
LICENSED CONTRACTORS DECLARATION 1 L Other—
hereby affirm that I am licensed under provisions of Chapter 9 Dap 1 Room Au Cond ?' L� OR
Class
(commencing with Section 7000) 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 p� y� d
Size 8 Type HP, KW KVA or KVAR x D VV R.- 0
J License Number Class
Up to 1 Incl FINAL
Over 1 to 10 Incl DATE VALIDATION Im
Contractor Date Over 10 to 50 Incl FINAL /� 0
11I am exempt under Sec Over 50 to 100 Inc BY y p� sVit
B BP C for this reason Over 100 (� N
Data Services Swbd , MCC B Ponelboards / ► Z
0 -200 Amp Under 600 V
Signature 201 - IODO Amp Under 600 V 2 6 0 2,5 A
❑ Exemption for Reg MainOver 1000 Amp or Over 600 V t Elect # . is • 0 • 2
SINGLE FAMILY Tamp Power Pole 8 Appurtenances
HOME OWNER-BUILDER DECLARATION ,Z • •
I hereby affvm that j exempt from the Contractors License Sign with One Branch Circuit 5 8 2 5
Law for the followingg r reason (Section 7031 5, Business and Additional Sign Branch Circuits -- • • • cJ 8 2 S�
Professions Code) ( O`,� T-83_8 y
❑ I as owner of the property will do the work and the Misc Conduits 8 Conductors
structure is not intended or offered for sole (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)
(Sec 3097, Civ C ) '
PLAN CHECKING FEE _
Lenders Name O
PERMIT ISSUING FEE
Lender s Address —
f /i
I certify that I have read this application and state that the TOTAL FEE ry 19 e:;!
above information is correct I agree to comply with all County
ordinances and State laws regulating Electrical wrong and ,
hereby authorize representatives of this County to enter upon '
the above men coned property for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
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Signature o Perminee D6te