HomeMy Public PortalAbout5045 SERENO DR_Electrical__ WORKERS COMPENSATION
ate of consent
to
CE 806 °'B' APPLICATION FOR ELECTRICAL PERMIT
1 hereby af4frR that I have-e certificate of consent to self assure, CE a08G n
OM dOrWobate of Workers Compensation Insurance or e certified COUNTY OF LOS ANGELES BUILDING AND SAFETY I ,ILMI
copy thereoJf'(S-e�c,3'8,00,/Lab C) �/
Polk; No /;t_(1� Company, �To7C-r�-/tD FOR APPLICANT TO FILL IN JOB
❑ Certified copy a hereby furnlshed /a NBvv Reedentsl Brigs d Pool EACH• NO .FEE ADDRESS
Sr — S LOCAIJTY'
❑"Cerhed cop/ a bled with the county Gnquig raspectlpn 1 d 2-Farms Sq FI '
deparknent Mulb-fainly Sq Ft
Date
2-9-92 gyp Residential Swimming Pools CROSS STOWNER OR
FAM NAME
CERTIFICATE OF EXEMPTKJN FROM WORKERS pullets Rec— Light —Sw MAIL
COMPENSATION INSURANCE Furst 20 ADDRESS
(This section need not be completed It the work ImoNed by the Total No Additional 20 pITV ' Tel No
permit W for one hundred dollars($100) or less) ` CITY
I cerbfy Mat in the performance of the work f« which the poral
CHECK
is issued I shall net employ any person In arty manner so es, to AmPUCANT _ '
became subject to the Workers Compensation Lowe Lighting Fixtures First 20 - ADDRESS , -
' Total No Additional Dots Applicant • CfTY Tel No
NOTICE TO APPLICANT Il, after making the Certificate of Fixed Appliances Not Over 1 HP pERN11T
Exemption,you should become subject to the Workers Compensation Range— Heater_ DW APPLICANT
Provsicna of the Labor Code,you must forthwith comply with such Oven — Dryer — Wm ADDRESS
7 -
prWhfgn9 or the Pernut shell be deemed revoked Top — FAU — W H CI7V �� Tel No2Z
LICENSED CONTRACTORS DECLARATION Hood _ Fan _ Other_ Ifl+
1 hereby OHirm that I am licensed under provtsana of Chapter g gyp — Room Am Card LICENSE OR
(commencing with Section 7000) of Drvsron 3 of the Business and REO NUMBER /� Clss -/O v
Professions Cafe and my(cense is in full force and effectDISTRICT NO D eY
Power Apparatus 8 L'arpe Apdences'
Sae d Type HP KW KVA or KVAR' or
License Number 8
S"�66 LJc Class G'l0 _ Up l0 1 Ind - FINAL
1�'I/�2
ContractorDate �� Z Over 1 to 10 Incl DATE VALJDATH)
Over 10 to 50 Incl
N
BY
BAP
S.1 eexempt under SOver 50 to 100 Inc FI
NAL
am
BAPC f«the reason Over 100 co
/-2,A-92 Services Swbd MCC 8 Panelboards Z
ate 0-200 Amp Under 800 V
Signature i�-I es, 201 - 1000 Amp Under 800 V
❑ Elect Exemption for Reg iOver 1000 Amp or Over 800 V '
SINGLE FAMILY - Temp Power Pole S Appurtenances
HOME OWNER-BULDER DECLARATION
I hereby affirm that I am exempt from the Contractora License Law 'with One french Circuit ACCT.t
for the foflowmg reason(Section 7031 5 Business end Professions Additional Sign Branch Circuits
Code) ao?7 ' 241.02
I as owner of the propertyunit do the work and the usi • - 1 IT
e net inteed peered 1« B
sale (section 7044, Business
Mac CoMrRs 8 Conductors Et1�
nd « aha(sea complete Fee schedule) — ► t TOTAL 2-41 . 02
and Professions Coda) • - t' '
CONSTRUCTION LENDING AGENCY ' DECK 241.112
1 hereby affirm that there Is a construction lending agent' for the
performance of the work f«which the permit is issued(Sec 3087 PERMIT FEE (Sub-Total) HAAh]E• .i,�Q
CN C)
Lenders Name
PIAN CHECKING FEE ,
Lenders Address
PERMIT ISSUING FEE _ 1J42 1 • AN11:31
�5l� ba
I certify that I have read the application and slate that the above TOTAL FEE v
Information is conect I agree to comply with all County ordinances
and'State laws, regulating Elecbcal wimp and hereby authonze
reprnsenWir,es of the County to enter upon the ahova-mentiapd -
propaty,for xspecbon purposes '
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date