HomeMy Public PortalAbout5242 SERENO DR_Electrical__ WORiCERSCOMPENSATION DECLARATION9DPW(,29„ APPLICATION FOR ELECTRICAL PERMIT IJ
I hereby affirm that I have a certificate of consent to sell 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 thereof I Sec'3800 Lab CC I t C� e, V.�
Policy No f z 7771�90d h" J FOR APPLICANT To FLLL IN � E�
IpPdt
Certified copy is hereby furnished New Residential Bitlgs &Pools NO EACH FEE
❑ ' ' 4Ad.f0 — LOCALITY C,ry JC Gf�
Certified copy is filed with tho cou busdn 1 &2 Family Sq Ft &. r+EARBsi
department Multi family Sq Ft CR038 ST ps ey
Date�as-y Cpl RaettlenVel Swimming Paola ` , ES,SOR
MAP BOOK PAGE PARCEL
CERTIFlCATE OF EXEMPTION FROM WORKERS Outlets Rec —Light Sw ow
RMN
NZ.' �L i I oV 1
COMPENSATION INSURANCE FIRI 20
(This section neeE not be completed If the work Involved by the MAIL
permit Is for one hundred dollars(&100j or lees) Total No Additional ADDRESS ioP, �r
I certify that in the performance of the work for which this permit 7,311
is issued I shall not employ any person in any manner so as to PLAN MEOK
become subject to the Workers,Compensation Laws Lighting Fixtures First 20 APPLICANT
i I Total No Additwnal
ADDRESS
Dere Applicant RESIDENTIAL APPLIANCES NOT OVER 3 HP
NOTICE TO APPLICANT If after making this Certificate ol, CITY TeI No
Exemption YOU should become subject to the Workers Compensation OTHER APPLIANCES NOT OVER 3 HIP
provisions of the Labor,Code you must forthwith comply with such APPLICANT X70 ` .sMf h E lei r L
Provisions or this permit shall be deemed revoked Power Apparatus&Large Appliances I I �+
LICENSED CONTRACTORS DECLARATION Size&Type HP KW KVA or KVAR ADDRESS "7'716 a.�^'I n Dr.
I hereby affirm'that I em licensed under provisions of Chapter B rk
(commencing with Section 7000) of Division 3 of the Business and Over 310 10 Ind CITU 2I
Professions Code and my license is in full force and affect Over 10 to 50 Incl }
LICENSE dA 1
222 Dyer 50 to t001nc1 REG NUMBER � 6 f a°°° L—�fl O.
License Numbers/J O I I Llc Class C—J O Over 100 DISTRICT NO PROCESSED BYE )
r/— C. Services Swbtl MCC&Panelboards
11
Contact L'+yC�l,jl� tIP.�1B ' C— / '7 0 399AMP Under800V P�� �
❑ I am exempt under Sec f+J J 4o6 1000 Amp Under 800 V VALIDATION W
Over f ODO Amp or Over 800 V pp1AL d
B&P C for this reasonBY 0
BRANCH CIRCUIT FEES
Date 15A or 20A 120V Lighting or Recept Z
1 To 10 Branch Grcuita ell
Signature 11 To 40 Branch Cncuite
41 Or❑ Branch Circuits
Exemption for Reg Malnt Elect 15A 20A 20 VV To 277V L A Br Orcusa
2
SINGLE FAMILY Temp Power P0I0&Appurtenances - �"�'�t
HOME OWNER BUILDER DECLARATION _
1 hereby affirm that I am exempt from the Contractor s License Law Sign with One Branch Circuit .1.1p.1�
for the following reason (Section 7031 5 Business and Professions Additional Sign Branch Circuits f LL[I
Code) I
❑ I as owner of the property will do the work and the structure Mier Conduits&Conductors _ __ _ _ - - - TOTAL 22$ - 15
Is not intended or offered for sale (Section 7044 Business Other(Sae Complete Fee Schedule) G
and Professions Code) CHECK ,15
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the ^
performance of the work for which this permit is issued(Sec 3097 PERMIT FEE (Sub Total) C
Civ C)
PLAN CHECKING FEE DOOMOO1 5/25/?3
Lender a Name r '- '—�—'
9935 PERMIT ISSUING FEE any 1 9x4
_
Lender a Address;
I certify that I here reed this application and under penalty of purjury state TOTAL FEE
that the above information is correct 1 agree to comply wah all County
ordinances and State laws regulating Electrics ring and hereby authorize
�imu
abovememgned property
S--2-r- 93 SEE REVERSE FOR EXPLANATORY LANGUAGE i
� agNATIIRE OF P MlE