HomeMy Public PortalAbout5043 SERENO DR_Electrical__ WORKERS C.OMPENSATIONDECLARATION 76"83CE80B ,D,ar APPLICATION FOR ELECTRICAL' PERMIT
1 hereby afppn Mat I have a certificate of consent to sett insure aoBO
oga certificate W workers Compensation Inaurarce or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof(Sec 3800 Lab C) .y r
PotCY No 16 (prppany S>a7��U FOR APPLICANT TO FILL IN JOB
❑ CerhhiKi copy Is �
hereby furnished 1:9-1/_ 9s New Resdenaal Bdps E FEE
Pools EACH NO ADpRE95
❑ • Certified copy Is hied with-the county budding Inspection 1 d 2-Family Sq Ft S — $ LOCALITY e .
deparMulti-family Sq Ft NEAFECROSq� I I
Dale'/ �z Applc' Residential Swannung Pooh C v R OR
FIRM NAME
CERTIFICATE OF EXEMPTION WORKERS Outlets RecLight — Sw MAL '
COMPENSATION INSURANCE ADDRESS-
(This section need not be completed N the work InvoNsd by the First 20
Tom do Additional CITY _ Tel Nig r
permit Is for one hundred dollars($100)«Ion), _i PLAN DECK
,I certify that in the Performance of the work for which this permit '
s Issued I shall not employ any person in any manner so as to - APPUCANT~
became subject to the Workers Campensaticn Laws Lighting Fixtures First 20 - ADDRESS ,
Date Applicant Total No Additional - CITY - - Tel No
NOTICE TO APPLICANT If after making this Certificate of Fixed Appliances Not Over 1 HP
WT
Range— Heat«— DW
Exemplicn,you should became subtest to subtto the Workere Compensation =UCANT_
Provsicrs o1 the Labor Code you must forthwith comply with such Ovan _ Dryer — W M — ADDRESS
,pranel«n«this permit shall be deemed revoked Top _ FAU _ WH U /l4
LICENSED CONTRACTORS DECLARATION Hood — Fan — Other_ CITU Tel No Z
I mhereby affirm that I am licensed under prowsiors of Chapter 8 Deep-_ Room Air Cond REE NUMBER �SCZ
_ Oleee C-/Q
(comencing with'Sectwn 7000) of Dmslori 3 of the Business and
Professions Code,and my license is in fill force and effectDISTRICT NO D BY
' Power Apparatus d Large Appliances
Size E Type HP KW KVA or KVAR J •Oil (LyC.t�(it� OQ.I
License Number /5�r , Lic Class--Lf-�=��2 - -Up to 1 Incl FINAL - v
Contract, Date /-2e-:Z2 Over 1 to 10 Incl DATE VALIDATION O
❑ lr/WOver 10 to 50 Ind FINAL 0
I am exempt undC Sec Over 50 to 100 Inc BY _ ttII,,II
88PC for the reason Over 100 N'
Date 1-Z R-9ea 2 SarvfcSwbd MCC 8 Panelboards , Z
0-200 Anis Under 800 V
Signature ' 201 - 1000 Amp Under 600 V
Over 1000 Amp or Ovar 600 V
❑ Exemption tar R"rt Elect
SINGLE FAMILY ' Temp Power Polar d Appurtenances i
HOME OWER-BUILDER DECLARATION Sign with One Brandi Circuit I+
I hereby affirm that I am exempt from the Contractors License Law' a� •� .ar
for the following mason(Section 7031 5 Buameas and Professions Additional Sign Branch Circuits -
Code) I 1 707 21.1:
❑ Miss Cprdeaa a Conductors - 1 ITEItr
I as owner the properly well do the work and the structure
BanddPPrt#en sd e=a Codeofiared f« sale (Section 7044 Business;
other(See Complete Fee Schedule) — - - i'► f.T n 240 _ 12'
CONSTRUCTION LENDING AGENCY - - ,_ E C`v1 240'U
I hereby affirm that there Is a corretrudem lending agency for the
Performance of the work for which this permit is skied(Sec 3087 PERMIT FEE (Sub-Total) CH �C!
Lenders Name
PLAN CHECKING FEE _ 137,30_0001 -1/27192
,
PERMIT ISSUING FEE pZ
Leader a Address 11379 1 AM 11:31J,
I carhly that I have read Mie application and state that the above TOTAL FEE ` a v AX • '
mf«matIDn is correct I agree to comply with all County ordinances
and State laws regulating Elecirrral wimp, and hereby authanze
repmaentatnes of the County to enter upon the above-menboned
property for inspedlon purposes _ - SEE REVERSE FOR EXPLANATORY LANGUAGE
Sigrshue of Permittee Date ,