HomeMy Public PortalAbout5235 SERENO DR_Electrical__ WORKER SCOMPENSATION DECLARATION ,B DPN(12 Bt) APPLICATION FOR ELECTRICAL PERMIT IJ
I hereby affirm that I lfave a certificate
consent of consent to sell Insure
or a cel'tificate or'Worker a Compensation Insurance or a certified COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV -
Copy thereof(Sec,3800 Lab C) L - 1,1
' �/y� `�}•
Policy No ComParry FOR APPLICANT TO RLL IN AGGRESS 5 E M1JV J l .
❑ "Certified mpy is hereby furnished , New Resdenual Bldgs $ NO EACH _FEE
— $• $ LOCALITY .
❑ Certified copy is filed with the county building inspection 16 2 Family Sq R _ NEAREST /
department Muto lem,ty Sq Ft CROSS ST
Deli'' ' "Appficem _ _ Reedemial Swimming Pools I ASSESSORj� o n�L
8001( o- , Q PAGE DI P/•ACEL A/
CERTIFICATE OF EXEMPTION FROM WORKERS Outlets Rec —Light Sw — 1 OWNER OR ' ' ` `
V
C-
I COMPENSATION INSURANCE } First 20 FIRM NAME
(This section need not be completed I1 the work Involved by the whit
Total No Additional
permit Is for'one hundred dollars($100)or less) ApORE95
I certify that ,n the performance of the work for'which'thle permit CITY `, Tel No
ie issued I shall not employ any person in any manner so as to PIAN CHECK
become subject to the Workers Compensation Laws Lighting Fixtures First 20 APPLICANT
Total NO Additwnel ADDRESS
TO
Date SLI Applicant rmw� RESIDENTIAL APPWWCES NOT OVER 3 HP
NOTICE'TO APPLICANT If after making this Certificate of CITY TO No
Exemption you should became subject to the Workers Compensation OTHER APPLIANCES NOT OVER 3 HP .. \\ ''11 yL ,. l
provisions of the Labor Code you must forthwith comply with such PERMIT
1'1 A 1v
provisions or this permit shall be deemed revoked Power Apparatus A Large Appliances
' LICENSED CONTRACTORS DECLARATION Size S Type HP KW KVA or KVAR ADDRESS "UV-
I hereby affirm that I em licensed under provisional of Chapter S Over 3 to 10 Incl
(commencing with Section 7000)of Division 3 of the Business and CITY TN No `•'�
Professions Cade and my license ie,n full force and effect Over 10 to 50 Ind
Over 50 to 100 Incl ONUMOR R O/
O Cb _1
LicenseNumxer Lc Class /-\0 d
Over 100 DLSTRIci No �� zv By U
Tq , `N •I' Services Swbd MCC 6 Panelbo ds
Contracts 1L� �`_` _• _ -Date J0 398 Amp Under B00 V _ DAVE 7 0
❑ I erre exempt untler Sec 400 1000 Amp Under 800 V _ (/ ~
Over 1000 Amp or Over 600 V, VALIDATION W
FINA
-B dP C for this reason - BRANCH CIRCUIT FEES BY �
Date 15A or 20A 120V Lighting or Recept Z
Signature - -- - -- " 1 To 10 Branch Circuits -
11 To 40 Branch Circuits
41 Or More Branch Circuits
❑ Eiempbon Is Rep Maine-Elect 15A 20A 209V To 27N Lighting Br Grcwis _ 7
SINGLE FAMILY Temp Power Pole 8 Appurtenances A��^
HOME OWNER BUILDER DECLARATION Sign with One Branch Circuli ryc+PL�`T 216.60
I hereby following
that I am exempt from the Contractor a License Lew Jw
for the/allow,np reason (Section 7031 5 Business and Professions Additronel Sign Branch Circuits -
Code)
❑ I et"net of the property will do the work and the structure Misc Conduits a Conducts - - -
Is not intended or offered for sale(Section 7044 Business Other(See Complete Fee Schedule)
and Professions Code) polf. - 1 ITEMS
CONSTRUCTION LENDING AGENCY - TOTAL - 2 1.6 - 60
I hereby affirm that there is a construction lending agency for the
performance of the work for which this permit is issued (Sec 3087 PERMIT FEE _ (Sub-Total) (JJE[t/ 216.A
Civ C) TjJ�'V4
PLAN CHECKING FEE _
Lander a Name PERMIT ISSUING FEE r��r� nf1 5/30/95
Lenders Address / W�0-0001
I cartily that I have reed this applicabun and under penetty of perjury stale TOTAL FEE �G. (O 1 pm 5,20
that the above information is correI agree to comply with all County
tt
ordinances and State laws regulating Electrical wring and hereby authorize
representativae of this County to enter upon the above-mentioned Property
for inspection pu SEE REVERSE FOR EXPLANATORY LANGUAGE
SIOMTURE OF PEAMnTFE WTE