HomeMy Public PortalAbout5080 SERENO DR_Electrical__ WORKERS CI haveSATIONcateDECLARATION
corse 'zaamcoaw3ie� APPLICATION FOR ELECTRICAL PERMIT O
I hereby affirm that I have o certificate of consent to self a�
insure, or a certificate of Workers Compensation Insurance I COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
or o certified copy thereof (Sec 3800 Lo -
PQluy NoAmpony_.� FOR APPLICANT TO FILL IN JOB O
aCertified copy is hereby furnished New Residential Bldgs EACH NO FEE ADDRESS y
trfied copy is filed with the county building inspec 1 &2-Family, Sq Ft 62S — S LOCALITY
tion par ent _ Multi-family Sq Ft — NEAREST
CROSS�O Residential Swimming Pools MW SMR
Da Appbcant ,
EIRM NNAMECE TIFICATE OF EXEMPTION F WORKERS MAIL
COMPENSATION INSURANCE Outlen Rec—Lig
_ ADDRESS
(This section need not be completed If the work involved by Total No First 20 - CITY el No
the permit Is for one hundred dollars($100)or less )' Additional
RAN CHECK
I certify that in ,he performance of the work far which this APPLICANT
permit is issued, 1 shall not employ any person in any manner Lighting Fixtures First 20 ADDRESS
so as to become subject to the Workers Compensation Laws
Additional
Date Applicant Total No CITY Tel No
IT
NOTICE TO APPLICANT If, after making this Certificate of Fixed Appliances Not Over 1 HP PMCATION
Exemption, you should become subject to the Workers Range— Heater—DW —
Compensation provisions of the Labor Code, you must forth Oven — Dryer —W M _ ADD
with comply with such provisions or this permit shall beTop FAU —W H
deemed revoked Hood — Fan —Other— CITY Tel
LICENSED CONTRACTORS DECLARATION Dup — Room Air Conal — 110ENS 11OR Cla
hereby affirm that I am licensed under provisions of Chapter 9 REG
(commencing with Section 7000)of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO P D BY d
and Professions Code oral my license is in full farce and effect , -f-190V_ Size &Type,HP, KW KVA or KVAR e_ t�t-� O
License Number n , c Class Up to 1 Incl FINAL 9 V
Over 1 to 10 Incl DATE /� a / VALIDATION cc
Contracto Dote Over 10 to 50 Incl Q
❑ I am ex m t under Sec , Over 50 to 100 Inc FINAL
P BY W
B 8P C for this reason Over 100 d
Services Swbd MCC 8 Ponelboorals , ' DO
Date
0 200 Amp Under 600 V ?
Signature 201 1000 Amp Under 600V
❑ Exemption for Reg Moint Elect Over 1000 Amp or Over 600 V
SINGLE FAMILY Temp Power Pole 8 Appurtenances
HOMEOWNER BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor s License Sign with One Branch Circuit L ITEm"
Low for the following reason (Section 7031 5, Business and - Additional Sign Branch Circuits - _
Professions Code) - TOTAL AL 1 13 - 30
❑ l m owner of the property, will do the work and the Mtsc Conduits&Conductors NECK 112,2-13
struincture is not intended or offered for sole(Section7o" Other (See Complete Fee Schedule)— Pilo �� I
� Busess and Professions Code)
4HM5E
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for IiQI313-13GO1 ° �' C I
the performance of the work for which this permit is issued PERMIT FEE - (Sub-Total) �� (J , may`"'
(Sec 3097, Civ C ) 7M I 4NlC1:_A
PLAN CHECKING FEE
Lender s Name PERMIT ISSUING FEE �� 1
Lender s Address TOTAL FEE
I certify that I have read this application and state that the
above information is correct I agree to comply with all County
ordinances and State jaws regulating Electrical wiring and ,
hereby thorize represent fives of this County to enter upon
the amentions pr V1'for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
nature a al ms