HomeMy Public PortalAbout5084 SERENO DR_Electrical__ DEC
TION
WORKERS'that
Ihave COMPENSATION cafe of corse 7 Wtvanvsiv APPLICATION FOR ELECTRICAL PERMIT 0
`t hereby affirm that I have a certificate of consent to sell asOba
insure, or a certificate of Workers Compensation Insurance, ` COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS
or a certified copy thereof (Sec 3800
Pr94cy No,r(, 0k/_a4ompony r '--` NM APPLICANT TO FILL IN JOB -
LJ Cartdied copy is hereby furnished New Residential Bldgs 8 Pool EACH NO FEE
iad copy is filed with the county building inspec- 1 8 2 Family, Sq F f — $ LOCALITY
tion d nm t Multi-family Sq Ft CROSSSST
Residential Swimming Pools OWNER
Date Applicant FIRM NAME
CERT ICATE OF EXEMPTION FROX WORKERS Outlets Rec_Light_Sw^ MAIL
COMPENSATION INSURANCE ADDRESS
(TMs stolon need not be completed If the work Imwlved byFirs 20 CITY Tel No
the pemn
slt Is for one hundred dollars($100)or Inas) Total No Additional
certify that ind ,I s performance of the work for which ilio AN CHECK
I APPLICANT
permits issued, shall not employ any person in any moaner
so as to become subject to the Workers'Compensation laws Lighting Fixtures Fust 20 ADDRESS
Additional
Total No CITY Tel No '
Dote Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT If after making this Certificate of APPLICAT
Exemption you should become subject to the Workers Range— Heater—DW —
y.
Compensation provisions of the Labor Code, you must forth Oven — Dryer —W M ADDRE
with comply with such provisions or this permit shall be T — FAU —W H —
deemed revoked Hood — Fan —Other— CINPodiel No
LICENSED CONTRACTORS DECLARATION Disp _ Room Air Cond LICEKSEClass
I hereby affirm that I am licensed under provisions of Chapter 9 RE NUMBER
(commencing with Section 7000)of Division 3 of the Business Power Apparatus 8 Large Appliances DISTRICT NO BYd
License NumLic Cla —
and Professions Code and my license is in full force nd effect v
/y`p , � Size 8 Type HP KW, KVA, or KVAR �Da O
ber Up to 1 Incl FINAL V
Contract to Over I to 10 Incl DATE Cj_ VALIDATION
❑ Over 10 to 50 Incl _ f-
FINAL
I am axe pt under Sec Over 50 to 100 Inc BY W
B 8P C for this reason Over 100 D_
Date
Services, Swbd MCC 8 Ponelboards Z
0 200 Amp Under 600 V
Signature 201 - 1000 Amp Under 600 V -
❑ Over 1000 Amp or Over 600 V
Exemption for Reg Moint Elect
SINGLE FAMILY Temp Power Pole 8 Appurtenances
HOME OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor s License Sign with One Branch Circuit y i
Law for the following reason (Section 7031 5, Business and Additional Sign Branch Circuits ACCT.T
Professions Code) - 3307 II`•i
❑ I as owner of the property will do the work and the Misc Conduits 8 Conductors I ITEM
structure is not intended or offered for sale(Section 7041 Other (See Complete Fee Schedule
Business and Professions Code) , TOTAL 1'15 - 75
CONSTRUCTION LENDING AGENCY I-HEIK Ili.��
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) CHANE .0f,
(Sec 3097 Cw C )
PLAN CHECKING FEE
Lender s Name PERMIT ISSUING FEE 0060-0001 6/25/51
Lender s Address TOTAL FEE 7704 1 AMICI: Ji
1 certify that I have read this application and state Thal the
above information is correct I agree to comply with all County -
ordinances and State laws regulating Electrical wiring, and
hereby authorize repress tatrves of this County to enter upon
the ve mentioned arty for inspection purpose
SEE REVERSE FOR EXPLANATORY LANGUAGE
ignature at tree to ®s