HomeMy Public PortalAbout5044 SERENO DR_Electrical__ WORKERS CIOMPENSATION DWLARATION 76A663 10/81 - 'AtPPLICATI64 FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of con"Ift to self CES' r
Insure or a cemficate of Workers Compensation Insurahce COUNTY OF LOS ANGELES 7— C+� 0 BUILDING AND SAFETY
or a certified copy thereof (Sec 3800 Lab C ) / /
i P❑allcy No Company FOR APPLICANT TO FILL IN JOBp
Certified copy is hereby furnished New Residential Bldgs 8 Pools EACH FEE ADDRESSJ
❑ Certified copy is filed with the county building inspec 1 &2-FomIly Sq Ft f — f LOCALITY /
tion department Multi-family Sq Ft 7 ,.'(, _ •d — NEAREST
Pools CROSS ST
Residential Swimming Poo
Date Applicant I OWNER OR
CERTIFICATE OF EXEMPTION FROM WORKERS Outlets Rec_Light_Sw_ MAIL
/ COMPENSATION INSURANCE ADDRESS
(This section nod not be completed If the work Inwhred by ! Fiat 20 CITY Tel No
the permit Is for one hundred dollars ($100)or leu) Total No Additional 4
PIAN ECK 39
I certify that in the performance of the work for which this - APPLICANT
permit is issued I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws Lighting Fixtures Flat 20 ADDRESS
Additional
Date /04Z&/Applicant �rs Total No CIN Tel No
NOTICE lb APPLICANT If after making this Certificate of Fixed Appliances Not Over 1 HP PERMIT //,, /L
Exemption you should become 'subject 10 the Workers Range_ Heater_D W _ APPLICANT K S Ld
Compensation provisions of the Labor Code, you must forth- ' Oven _ Dryer — W M _ ADDRESSOX 7p
with comply with such provisions or this permit shall be Top — FAU —W H /
deemed revoked Hood _ Fan _Other_ CITY �l Tel No 9�fs.6n!♦/
LICENSED CONTRACTORS DECLARATION LICENSE OR
I hereby affirm that I am licensed under provisions of Chapter 9 r Disp _ Room Au Cond REG NUMBER 3 Class e_/o '
(commencing with Section 7000) of Division 3 of the BusinessDISTRICT NO D BY
and Ptofesswns Code and my license Is in full force and effect Power Apparatus 8 Large Appliances d
) ///� �� i Size 8 Type HP KW KVA, or KVAR � � • Q
License Number 410Z3L99Z Uc Class L� /D FINAL V
,F', Up to 1 Incl
.�iGL L`sEl�tr.�l! 2 �� Over I to 10 Incl DATE —�� VALION
Contractor Date Over 10 to 50 Incl O
❑ I am exempt under Sec FINAL
P I Over 50 to 100 Inc BY d
B 8P C for this reason Over 100 Z
Sery
p Z ices Swbd MCC B Ponelboards
Date ► G/U
0 -200 Amp Under 600 V
Signature c'f i 201 - 1000 Amp Under 600 V
❑ Over 1000 Amp or Over 600 V Q 81' Q
Exemption for Reg Maint Elect I �
SINGLE FAMILY Temp Power Pole 8 Appurtenances
HOME OWNER BUILDER DECLARATION Sign with One Branch Circuit I( - 7675
�
1 hereby affirm that I am exempt from the Contractor s License i
Law for the following reason (Section 7031 5, Business and Additional Sign Branch Circuits �_ e 1,76755,76 ,755
Professions Code)
❑ +
as owner of the progeny will da the work and the Mix Conduits 8 Conductor I Q02-84 ,
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 ,
PERMIT ISSUING FEE
Lender s Address
I certify that I have read this application and state that the TOTAL FEE
above information is correct I ogres to comply with all County _
ordinances and State laws regulating Electrical wiring and
hereby authorize representatives of this County to enter upon
the above me coned r per for inspection purposes r
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee