HomeMy Public PortalAbout5041 SERENO DR_Electrical__ WORKERS COMPENSATI to of consent to
Teaaaa ,D,a, APPLICATION FOR ELECTRICAL PERMIT n
{ hiereby eNrm that I have a certificate of consent to sell insure �aae0
Cr a oatd�cals of Workers Compensation Insurance, or a cerbfed COUNTY OF LOS ANGELES BUILDING AND SAFETY, ILII
odpy thereof(Sec 3000 Lab C) p / '
Policy No 42 2 V" (gn�Par�y:5� t/Nd FOR APPDCANT TO RLL IN JO
ElCad rbfecopy a hereby furnished G New Residential Bldgs d Poole EACH NO FEE ADDRESS
❑ Certified Copy a filed with the county buckling inspectionI It 2-FamilY Sq Ft S v — LOCALITY
department Multi-family SII Ft NEA14ES'T
CFKM ST
Date... Z�AppL,penh Residential Swimming Pools OWNER OR ^,
FIRM NAME
CERTIFICATE OF EXEMPTION FROM V&ERS AIAtL
COMPENSATION INSURANCE Outlets Rex— Light _ Sw ADDRESS ,
Panni aesectioncorn~leled d need nlos cod the work Involved firs'20
by the
permit Is OM hundred Ohuddled dollars(SI00)or Iet1D) Total No Additional L CITY Tel No
PLAN CHECK
I Certify that in the performance of the work for which the permit APPLICANT
a Isaed 1 shall not employ any person in arty manner so as; to
become Subject to the Workers Compensation Laws _ Lighting Fixtures First 20 ADDRESS -
Additional
Date ApplicantTotal No CITY Tel No
,NOTICE TO APPLICANT If after making the Ccrtticate of Fixed Appliances Not Over 1 HP PERMIT
Exemption you should become subject to the Workers Compensation Range— Heater_ DW _ APPLICANT -
Ae
provieiors of the Labor Coda you must forthwith comply with such Oven _ Dryer _ W M _ ADDRESS
pioviame or the peanut shall be deemed revoked Top _ FAU WH _ pr
-
LICENSED CONTRACTORS DECLARATION Hood — Fan Other_ CITY Tel No - Z 2
I hereby affirm that I am Incensed under provisions of Chapter 9 Dnsp _ Room Air Cond i UCENBE Off ' 6 C" -��
(Cpmmericing with Section 7000) of Division 3 of the Buaneea and REG
Profesacre Code and my license a//in full force and a/Nec_t,', power Apparatus S Large Applericas DISTRICT NO
License Number11�ts LIC Class (_/V Sae 8 Type HP
to KIN
or KVAR _ FINAL 11� /J
Contractor Date 2
Over 1 to 10 Ind _ DATE II.` 1 "{7iv VALIDATION I0-
��t', �tr Over 10 l0 50 Incl FINAL U
❑ I am exempt un er Sec Over 50 to 100 Inc By 13
SAPC for the reason �/ Over 100 N
Date -��—�.Q 9797 Services Swbd MCC B Panelboads
0-200 Amp Under 600 V
Signature R 201 - 1000 Amp Under 600 V i
❑ Exemption for Over 1000 Amp a Over 600 V ,
Reg Mamt Elect
SINGLE FAMILY Temp Power Pole 8 Appurtenarnces
HOME OWNER-BUILDER DECLARATION Sign with One Branch Cimud r i
I hereby affirm that I am exempt from the Contractors License Law ACCT.:
for the followinBranchng reason(Section 7031 5 Business and Professions Additional Sign Brach Circuits•- - - - - -
Cade)
33l17 243 t-,
❑ I
Busmen
Mmc Corduts 8 Conductors - 1 ITEM` -
ore omen of the property will do the work and the Blre
e not intended or offered ion far sale (Sect7044 &miners Other (See Complete Fee Schedule)
and Profesalora Code), TOTAL 243 - 45
• CONSTRUCTION LENDING AGENCY CHECK
I hereby affirm that there a a construction lending agency for the
performaice of the work for which the permit is issued(Sec 3097, PERMIT FEE (Sub-Total) i_HANSE
Civ C)
PLAN CHECKING FEE -
LerxieraNeme '/
nders i JC10C1—CIQC11 1/.'.77'_
PERMIT ISSFEE -7-
that
I Address
reUING
I cerbty tthat haad this epplioion etend este that the above ���e TOTAL FEE _ - r _
information W correct I agree to comply with all County ordiriarpes
end State laws regulabng Electrical wiring and hereby authnonze
atmas of the County to enter upon the above-mentioned
rty for inspection purposes - SEE REVERSE FOR EXPLANATORY LANGUAGE - -
nature of Permittee Date i '