HomeMy Public PortalAbout5113 SERENO DR_Electrical__ vWORKER SaveCOMPENSATIONcertificate
DECLARATION M DPW(12 9„ APPLICATION FOR ELECTRICAL PERMIT
li)ereby a/lrm that I have a certtlwete of consent to self Insure
or a certificate of Worker a Compensation Insurance or a certified COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV
copy thbreof(Sec 13800 Lab�J�j - ♦ r�
Policy No 6�� ipany J u `^I ALL I'OR APPLICANT TO EnL IN JOE
gpORE9s
❑ Cenifi,db copy is hereby fumteRed" ' � New Residential Bldgs 8 Paola NO EACH FEE LOCALfTY
❑ - G U
Certified copy is filed with the county,buuding impaction• 1 8 2 Famiy So Ft a0 — 11 11 NEMEST
Oaperbnent Multi family Sq Ft CROSS V
Date i J Applicant'
pplwResidential Swimming Poole
ASSESSOR
yApE O
001( PAOE PN10El
CERTIFICATE OF EXEMPTION FROM WORKERS Outlets Reece Light!W Sw Ail:-- FOI MENAME
COMPENSATION INSURANCE ' a First 20 l
(This eeetlon need not be completed If the work Invoked by the CESS �Q t
permit Is for one hundred dollars(11100)or less) Total No� A4dnwnel `•
I candy that in the performance of the work for which this permit CITY eJ Ta No
is issued I shell not employ any person in any manner so as to PLAN CHECK
become subject to the Workers Compensation Laws Lighting Fixtures First 20 APPUCANT
Total No Additional
ADDRESS (A
Dere Applicant RESID94 IAL APPLIANCES NOT OVER 3 HP -
NOTICE TO APPLICANT a after to the this Certificate of CITY
Exemption you should become subject t:the Workers Compensationwitsch OTHER APPLIANCES NOT OVER 3 HP
provisions of the Lebon Code you timet forthwith comply with each PERU provisions or this permit shall be doomed revoked Poser Apparatus d Large Appliances �UCANT
"' LICENSED CONTRACTORS DECLARATION Size 3 Type HP KW KVA or KVAR ADDRESS _
I herebylalfirm that 1 am licensed under provisions of Chapter 9 Over 3 to 101x1
(commencing with Section 7000) 01 Division 3 of the Business and CITY Ta No
Professions Code and my license is in full force and effect Over 10 to 50 Incl
LI
Over 50 to 100Incl REG NNWIBER Class a
Over 11X1 DISTRICT NOP By Q
License Number vL/ Uc Class 1 („)
Services Swbd MCC 8 Panelboards - t Q
Cantrecto)V �j (�FnC 11
0
Date `3 � 0 393 Amp Under 600 V D -
❑ I am exempt under Sec 400 1000 Amp Under 000 V 4/ VALIDATION V
Over 1000 Amp or FINAL 600 V FINW
B 8P C for this reason - a
BRANCH CIRCUIT FEES By co
Date ISA or 20A 120V Lighting or Recept Z
1 To 10 Branch Circuits
Signature 11 To 40 Branch Circuits
41❑ Exeirfor Reg Mamt Elect 15A 20A,205V To 277VLi More BB G�
iDtian
SINGLE FAMILY Temp Power Pole 8 Appurtenances 'L
HOME OWNER BUILDER DECLARATION 'Sign with One Branch CircuitT
I hereby affirm that I am exempt from the Contractor a License Lew
for the Code) following reason (Section 7031 5 Business and Professions Additional Sign Branch Circum 03 - �li�•-•,
r
F1 as owner of the property will do the work and the structure Mie: Conduits 6 Conductors 1 I 1rGN5
is not intended or offered for sale(Section 7044 Business Other(See Complete Fee Schedule)
-
and Profeeswns Code) , 'OI AL ? 11 w A.P T p
CONSTRUCTION LENDING AGENCY - y CHECK 211.8:
1 hereby affirm that there is a construction lending agency for the _ !_HMGE x130
performance of the work for which this permit is issued (Sec 3097 PERMIT FEE (Sub-Total) A,,
Civ C)
Lender s Name PLAN CHECKING FEE - 0000-0001 6/30/?1
PERMIT ISSUING FEE �(p in
c 1
Lender a - FRIJ
::
I Carly that I have
read this applwetion entl under penalty of pu0ury slate TOTAL FEE O �
that the above information m correct I agree to comply with all County
ordinances and State leve regulating Electrical winng and hereby eulhonne
repreeenteWes of this County to enter upon the above-mentioned property
for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
_?1B TURE W ERMn1EE 0 GATE I