HomeMy Public PortalAbout5120 SERENO DR_Electrical__ WORKERS COMPENSATION DECLARATION uCE_ 63 ,D,Bt APPLICATION FOR ELECTRICAL PERMIT
I hereby off
m that I have a certificate of consent to self CEG
insure or a certificate of Workers Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified
!copy thereof (Sec 3800 Lob C )
Policy No c-y(1-Company AVVX1127e77� FOR APPLICANT TO FILL IN JOB
Certified copy is hereby furnished New Residential Bldgs 8 Pools EACH NO FEE ADDRESS
2�enihed copy is filed with the county builds Spec- 18 2-Family, Sq Ft 2470 $ = S LOCALITY
I epa a Multi famJy$q Ft6 NEAREST
G CROSS ST
Date / �� o AppLcan Residential Swimming Pools OWNER OR f!
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS Outlets Rec_Light_Sw_ MAIL
COMPENSATION INSURANCE ADDRESS
(This section need not be completed If the vrork Involved by First 20 _ CITY I No
the permit is for area hundred dollars ($100)or less) Total No Additional /
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 APPLICANT
so as to become subject to the Workers Compensation Laws Lighting Fixtures fent 2O ADDRESS -
Total No Additional
Data Applicant CIN Tel No
NOTICE TO APPLICANT If after making this Certificate of Fixed Appliances Not Over 1 HP PERMIT
_ Heater_D W _ APPLICANT
Exemption you should become'subject to the Workers Range
Compensation provisions of the Labor Cade, you must forth Oven _ Dryer —W M _ ADDRESS
with comply with such provisions or this permit shall be Top _ FAU _WH _
deemed revoked CIN Tel N
H
- LICENSED CONTRACTORS DECLARATION ood _ Fan _Other_
I herebyaffirm that I am licensed under p Disp — Room Air Cond LICENSE 2 i _ Claas��0
provisions of Chapter 9 REG NUMBER :J
(commencing with Section 70DO)of Division 3 of the Business Power Apparatus&Large Appliances _ _ _ DISTRICT NO. PROCESSED BY !
and Professions Code and my license is in full face and effect d
q Size 8 Type HP, KW, KVA, or KVAR i �D O
License Number -3/ Lm Class Up to 1 Ind FINAL V
�d / p Over 1 to 10 Incl DATE C�` ys �'� VALIDATION
Contractor Over 10 to 50 Incl o U
❑ FINAL /
I am exempt under Sec Over 50 to 100 Inc BY W
B 8P C for this reason Over 100
Date Services MCC 8 Panelboards , /�
0 -200 0 Amp Under 600 V
Signature 201 - 1000 Amp Under 600 V
❑ Over 1000 Amp or Over 600 V
Exemption for Reg Maent Elect
SINGLE FAMILY Temp Power Pole 8 Appurtenances _
HOME OWNER-BUILDER DECLARATION - Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor s Licensew •��) 4 Q .3 a
Lafor the following reason (Section 7031 5, Business and Additional Sign Branch Circuits _ -
Professions Code) r # • • • • • 2
❑ I, as owner of the property will do the work and the Mix Conduits 8 Conductors 21-,* 9 Q.5 Q
structure is not intended or offered for sole (Section Other (See Complete Fee Schedule)_ ►
7044 Business and Professions Code) s rs e 9'4 5 0
CONSTRUCTION LENDING AGENCY l
1 hereby affirm that there iso construction lending agency for 5 2 2-$4
the performance of the work for which this permit is issued - PERMIT FEE - - - (Sub-Total) _.
(Sec 3097 Gv C )
) PLAN CHECKING FEE
Lender's Name
t
PERMIT-ISSUING FEE
Lenders Address
I certify that I have read this application and state that the TOTAL FEE
above information is correct I agree to comply with all County t
ordinances and tate law-Ligoulating Electrical wiring and
hereby authors repr rve of this County to enter upon
the a -m tion r f spectio p Is
SEE REVERSE FOR EXPLANATORY LANGUAGE _
Sig tura e e Da