HomeMy Public PortalAbout5082 SERENO DR_Electrical__ P
WORKERS CI have COMPENSATIONDECLARATION
of
Io�w„V APPLICATION FOR ELECTRICAL PERMIT O
hereby affirm that I have a certificate of consent to self eoec
insure or a certificate of Workers Compensation Insurance COUNTY OF LOS ANGELES DEPT, OF PUBLIC WORKS
or a certified copy thereof (Sec 3800,1E
Policy N./ ompany FOR APPLICANT TO FILL IN ,OB
Certified copy is hereby furnished New Residential Bldgs 8 00l EACH NO FEE ADDRESS
Certified copy is filed with the county building inspec- 1 8 2-Family Sq Ft $ — E 0 LOCALI
hon all partme Multifamily Sq Ft NEARESTT I
CROSS
Date Apphcant , �. Residential Swimming Pools
FIRM NAME
CERTIFI TE OF EXEMPTION FRO WORKERS' Outlets Rec�Light_Sw— MAIL
COMPENSATION INSURANCE First 20 ADDRESS
(This sectlon need not be completed If the work Involved by Total No Additional CITY Tel No
the permit Is for one hundred dollans($100)or loss )
I certify that in the performance of the work for which this PLAN CHECK
permit is issued I shall not employ any person in any manner
so as to become subject to the Workers'Compensoaon Laws ADDRESS
Fixtures first 20 APPLICANT ADDRESS
Total No Additional
Date Applicant CITY Tel No
NOTICE TO APPLICANT If, after making this Certificate of Fixed Appliances Not Over I HP PERMIT
Exemption, you should become subject to the Workers' Range— Heater—DW APPLICATION
Compensation provisions of the Labor Code you must forth- Oven — Dryer —W M _ ADDRESV 1k
with comply with such provisions w this permit shall be Top — FAU —W H el N
deemed revoked Hood — Fan —Other— CITY '
LICENSED CONTRACTORS DECLARATION Dlsp — Room Air Cord L O
I hereby off irm that I am licensed under provisions of Chapter 9 REG NUMBER CIO
(commencing with Section 7000)of Division 3 of the Business Power Apparatus 8 Large Appliances DISTRICT NO
and BY Y
8
and Professions Code,and my license is in full force and effect Q yv U
_ Size Type HP, KW, KVA, or KVAR O
Q.
License Number $ Iic Clan U
Up to 1 Incl FINAL q
Cr
Contractor to Over 1 to 10 Incl DADATE /��/� VALIDATION 0
❑ Over 10 to 50 Incl
I am exe t under Sec Over 50 to 100 Inc BY AL U
B 8P C fee this reason Over 100 Ell
a
Date
Services, Swbd , MCC 8 Ponelbcards , _ U)
0 200 Amp Under 600 V z
Signature 201 1000 Amp Under 600V
Exemption for Reg Mamt Elect
Over 1000 Amp or Over 600 V
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Temp Power Pole 8 Appurtenances i
I hereby affirm that I am exempt from the Contractor s License Sign with One Branch Circuit r i
Law for the following reason (Section 7031 5, Business and Additional Sign Branch Circuits ACCT.r ,
Professions Code) `
❑ I as owner of the property, will do-the work and the Mix Conduits 8 Conductors 1 7TEH=
structure is not intended or offered fee sole(Section 7044 Other (See Complete Fee Schedule)_
Business and Professions Code) pop. 122 $5
CONSTRUCTION LENDING AGENCY CHECK 122.E5
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) CHAHVE .IJO
(Sec 3097, Civ C )
PLAN CHECKING FEE
Lender s Name
PERMIT ISSUING FEE
Lender s Address ..7E O .�L�� 1 A�11J�r1
I certify that I have read this application and state that the TOTAL FEE �p�ps. D
above information is correct I agree to comply with all County
ordinances and State lows regulating Electrical wiring 'and
hereby thorize represent ives of this County to enter upon
thea mentioned p rry for inspection urpo SEE REVERSE FOR EXPLANATORY LANGUAGE
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gnature o. P itty ate – ms