HomeMy Public PortalAbout5111 SERENO DR_Electrical__ WORKSPENSATX)NDECLARATION 7&M63 APPLICATION
APPLICATION FOR ELECTRICAL PERMIT -"
I herdby ailyfn MettINeve ave a certificate of consent to Bell insure
or a certiflFAte•of Worker a Compensation Insurance or a certified COUNTY OF LOS ANGELES DUCPT OF PUBLIC WORKS BUILDING AND SAFETY DIV
cop�thl,reol{Sec 3000 tab - _ , ,
Policy No p r-0R APPLIGNT TO FILL IKZO
RE99
[_] 'CeMatl ropy is hereby lumrehed New Residential Bldgs 8 Pads Pro EACH FEE
❑ Ceridred copy w filed with the county building inspechon 1 8 2 Family Sq Ft I — 3 3 LOC
AU
NROSS T
, dapenment A� Multi family Sq Ft �S BT '
¢� L' \ YL j�J Reedenbal Swimming Pools - ASSESSOR
Date Applicant T_
NAP 8001( PAGE PMCFl
CERTIFICAT OF EXEMPTION FROM WORKERS Omj�s Ra s S _ OWNER on
COMPENSATION INSURANCE � HRM NAME
First 20 MAIL
(This"action neetl not w completetl LA
If the work Involved by the Total No Additional ADDRESS 343• f
permit Is for one hundred dollars(3100)or lees)
I certify that in the performance of the work for which this permit �` _ P_Z�..� �- CITY
is issued I shall not employ any person in any manner so as to PLAN
ECK
become subject to the Workers Compensation Laws Lighting Fixtures First 20 L�CH
oANT
Total No Additional
' ADDRESS
Date " Applicant RESIDENTIAL APRJANOES NOT OVER 3 HP
NOTICE TO APPLICANT If after making this Certificate of CITY Tel No
Exemption you should become subject to the Workers Compensation OTHER APPLIANCES NOT OVER 3 HP
provisions of the Labor Code you must forthwith comply with such PERMIT
provisions or this permit shall be deemed revoked
Power Apparatus d Large Appliances APPLICANT
' LICENSED CONTRACTORS DECLARATION Size 8 Type HP KW KVA or KVAR ADDRESS
I hereby affirm that I em licensed under provisions of Chapter B Over 3 to 101nc1 J
(commencing with Section 7000)of Division 3 of the Business and CITY TN
Professions Code end my license is in full force and effect Over 10 to 50 Incl }
Over 50 to 100 IrCl REO NU BER CMu G.
License Number _Vc Class. . Over 100 DISTRICT NO Essen BY 0
t� Services Swbd MCC 8 Parelboerde p 7, "(
COTtractor AIN eBA)T%A�'7� Date 6- IT 0 3Bg Amp Under 000V DRRAEAn 1' �/ 0
❑ I am exempt under Sec 400 1000 Amp Under 60O V - DAiE VALIDATION W
Over 1000 Amp Or Over 800 V FltNL _ d
B aP C for this reason BY
BRANCH CIRCUIT FEES Z
Dale 15A or 2GA 120V Lighting or Recept
1 To 10 Branch Circuits
Signature 11 To 40 Branch Circuits -
❑ Exemption for Reg Maint Elect ISA 20A 208V To 2M Ug"More&rests
41 Or 7
Branch Circuits
SINGLE FAMILY Terrip Power Pole 8 Appurtenances
HOME OWNER BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractors License Lew .
for the following reason (Section 7031 5 Business and Professions Addibonm Sign Branch Circuits .i:�5 cif S�`4,
Code)
❑ i ITEMS
I as owner of the property or al (S work and the structure Mist Gonduits Co A Cte I" c ' TOTAL 2 1 I- v9
Is not intended or altered for eels (Section 7044 Business Other(See Complete Fee Schedule)_ ,
and Professions Code) ty HECr 11.39
CONSTRUCTION LENDING AGENCY `.�NE. �(I
I hereby affirm that there is a construction lending agency for the p -
performance of the work for which this permit is issued (Sec 3007 PERMIT FEE (Sub Total) /OS
Civ C) IL
PLAN CHECKING FEE 1)IkO-0I)01 6/30/94
Len0er s Name PERMIT ISSUING ISSUING FEE � Q 5903' i A`I 9•34
Lender a Address
I certify that I here read this application and under penalty of pugury state TOTAL FEE �•
that the above infor nebon a correct I agree to comply with all County
ordin tines and State Jews regulating Elecincal wining and hereby autlg
representatives,of dus County,to enter upon the above-mentioned property _
for mepection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
OaNA01�PEfeeTTEE DATE ,