HomeMy Public PortalAbout5039 SERENO DR_Electrical__ WORKERS COMPENSATION DECLARATION to
CE7MO63906 ,D,a, APPLICATION FOR ELECTRICAL PERMIT
I=.endyi that I ria� a certificate d consent to aeI insure �atle0 � I
f.10 Whrker§ Compenseton Insurance or a calitad COUNTY OF LOS ANGELES BUILDING AND SAFETY U
copy tiered'(Sec 3,0'00/Lab C)
Policy No(.2.7�� Conmpeny43_ FOR APPLICAM TO RLL IN JOB O
Certiletl copy a hereby fyrrxshetl � New Rasdental Bldgs d Pools EACH NO FEE ADDRESS 5t)-3 Y
E] Cerobed copy rs bled with the county building inspection 1 & 2-Family Sri Ft 236] [� $'4:F LOCALITY—
department I Muhrfemily Sp Ft — NEAREST
CROST
Pete J—��� Applicant Residential Swrnming Poole OWNER OR `
f FIRM NAME
CERTIFICATE OF EXEMPTION FROM RKERS i v MAL
COMPENSATION INSURANCE Outlets Rec_Light ADDRESS
(This section need not be canpleled it the work awoNed by the , First 20
psmmt re for ons hundred tlarers,(s 100)mien)
Total No Addihonal CRY Tel No
1 certify that in the performance of the work for which this permit _ ' ' PLAN CHECK
is issued I shall not employ any person in any mender vso-as to APPLICANT ,
became subject to the Warkers Compensa on Lens Lighting Fixtures First 20 - ADDRESS
Data Applicant - Total No Additional CITY - Tel No
NOTICE TO APPLICANT R after making ,this Cereficete d Fixed Appliances Not Over 1 HP , PERMD
Exemption you ald become sublact to the Workers Compensation Range— Hester— DIN _ 'IT
hou
provisions of the Labor Code you moat forthwith cartery vmh such Oven _ Dryer — W M — - - ADDRESS
n
povieens or this permit 911e1 be deemed revalcndTop — FAU _ W H _ `
LICENSED CONTRACTORS DECLARATION Hood — Fan _ Other_
CITY C Tel No 'ft `
I Hereby affirm that 1 am licensed under provisions of Chapter 9 Osp — Rppm Air Gond " NUM�R Gma G p
(coninenoug with Section 7000) of Division 3 of the Busmam and
Profeaeione Code and my license us in full face and cited DISTRICT NO PROCE ED
6 Power Apparatus 8 Large Appliances D p
�!--//�-T Sae& Type HP KW KVA or KVAR o Co•'
License Number Lc Class� Up to 1 Ind FINAL 8
Over 1 to 10 Ind r DATE -( _9 2— VALIDATION
Contractor Data Over 10 to 60 InG
FINAL
❑ I sin exempt order Sec over 50 to 100 Inc_ B1' {�J
SAP for this reason Over 100
Tete Services Swbd MCC& Penelboards - Z
�j 0-200 Amp Under 600 V
"ignatu r, 201 - 1000 Amp Under 600 V -
❑ �� Over 1000 Amp or Over 600 V -
Exemption for Reg Maim Elect
- " SINGLE FAMILY Temp Power Pole & Appurtenances "
HOME OWNER-BUILDER DECLARATION Shit with One Branch Circuit ' y
I hereby affirm that I am exempt from the Contractor's License Leiv +
for the lallowirg reason(Section 70315 Business Additional Sign Branch Cvcuits ACCT.r
sa and Proles
Code) s 3307 _:7.?�
❑ 1 as owner of the property,will do the work and the structure Mac Conduits& Conductors '
e intended not Inteed or offered for sale (Section 7044, Business Other(See Complete Fee.Schadule) — I FTEMS -.
and Professions Cade) TOTAL , 2 �.'7
CONSTRUCTION LENDING AGENCY _ _ CHECK _�7 a,
I hereby affirm that there is a construction lending agency for the
performance Of the work for which this permit is aeuad(Sec 3097 PERMIT FEE (Sub-Total) CHAN1- .U(I
CN C)
PLAN CHECKING FEE '
Lentlere Name PERMIT ISSUING FEE r � 131303-1210101 1/t7/92
Larders Address
1741 1 A1111:31
I oertdy that I have read this application and state that the above TOTAL FEE
information Is Correct I agree to comply oath all C aunty ordinances
and State laws regulebrg Electnrcal vrnrg, and hereby authorize
representatives of thin County to enter upon the above-mentioned -
prop" for ifepwbal purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
Sig
nature of Permittee Date ,